How 8 years of poor disinfection exposed a darker side of Air Force medical practices.
Despite several deaths and increased attention to the reprocessing of endoscopes, it seems that outbreaks involving the medical devices are becoming a new norm. Last week the Air Force reported that 135 patients were potentially exposed to HIV, hepatitis B and C, and other blood-borne pathogens during an 8-year span. The exposures occurred between 2008 and 2016 at a clinic within Al Udeid Air Base in Qatar. The endoscopes involved were used to perform upper and lower gastrointestinal procedure and it was found that the disinfection practices were not being followed.
Although this exposure is different than the infamous outbreak of carbapenem-resistant Enterobacteriaceae (CRE) at University of California, Los Angeles (UCLA) Medical Center, it highlights the consistent disinfection issues associated with endoscopic equipment and procedures. The UCLA outbreak involved duodenoscopes and design flaws that made disinfection extremely challenging. This recent exposure involving the base in Qatar is centered around poor disinfecting practices between procedures. The endoscopes were not cleaned according to US Food and Drug Administration (FDA) guidelines and further review found that the medical technicians responsible for disinfection used “an alternate method that included manual cleaning and inspection, rather than the recommended automated process. Specifically, it was noted that during equipment reprocessing, the flushing and brushing of the scope lumens were not completed as recommended by the manufacturer.”
This is particularly concerning on several levels—first, given all the attention that was placed on duodenoscope reprocessing, healthcare facilities have ramped up disinfection monitoring methods for all flexible endoscopes to ensure compliance and avoid adverse events. Was this increased scrutiny not present at the Al Udeid clinic?
Second, how did such poor disinfection practices go unnoticed for 8 years? Validating employee competencies is crucial and should always be ongoing practice. A medical culture that fails to identify these practices or turns a blind eye is extremely concerning. Upon these findings, they should have been doing a substantial deep-dive into all other disinfecting and sterilization practices. (According to the Air Force, they have taken preventive measures at the clinic following the finding, including issuing a patient-safety alert, reviewing procedures, and stopping the associated procedures with the endoscopes.)
Third, how was this violation found? Given the length of time these poor practices persisted, perhaps a shift to a culture of Just-In-Time practices is needed, which highlights drawing attention to near misses as a learning, rather than punitive, tactic.
Lastly, as I mentioned before, it is concerning that this 8-year exposure is not related to a defective or intricate product that caused issues despite proper practices, but rather this was due to poor practices and a complacent approach to monitoring and validation.
The exposure of 135 Air Force men and women to blood-borne pathogens because poor disinfecting practices were done over the course of 8 years could have easily been prevented. Although Veterans Affairs and other veteran healthcare facilities employ infection preventionists, I wonder if military clinics in foreign bases are receiving the same kind of surveying and attention to infection control practices. The exposures at Al Udeid should act as a stark reminder to us about the importance of disinfection; and, that despite the nuances of the procedures, they are vital to patient safety. Validation of competencies and safe practices is easily overlooked during a time of increased pressure on healthcare workers and financial struggles; however, this is one avenue that we must maintain vigilance.