HospitalInspections.org

Based on interview and record review the facility failed to ensure a process for reprocessing of endoscope (an instrument introduced into the body to give a view of internal parts) equipment that adhered to professional society (Association of periOperative Registered Nurses (AORN), Advancement of Medical Instrumentation (AAMI) or American National Standards Institute (ANSI)) recommendations. This failed practice could lead to multidrug-resistant bacterial infections in all patients who have undergone Endoscopic Retrograde Cholangiopancreatography (Procedure that combines endoscopy and X-rays to examine and treat conditions of the bile and pancreatic ducts).

The findings are:

A. On 07/14/2022 at 10 am, in an interview with S(staff) 4, Chief Nursing Officer, when asked about endoscope reprocessing procedure stated, "We follow manufacture guidelines, we do not follow AAMI, ANSI or AORN."

B. On 07/15/2022 at 10:20 am, in an interview with S16, Gastrointestinal Tech, when asked if they follow the recommendations of AAMI, ANSI or AORN for reprocessing of endoscopes, duodenoscopes and bronchoscope stated, "No, we just follow the manufacturers guidelines"

C. Record review of facility's policy titled "Anesthesia Cleaning and Infection Control," revised on 09/2019. Item 1.3 States "Other equipment will be cleaned/sterilized according to manufacture recommendations."

D. Record review of manufactures Instructions For Use (IFU) titled "Reprocessing Manual for Gastrointestinal Videoscope, Colonvideoscope and Bronchovideoscope" on page 2 states, "When selecting appropriate methods and conditions for cleaning and disinfection and sterilization, follow the policies at your institution, applicable national laws and standards, and professional society guidelines and recommended practices, in addition to the instructions given in this manual."

Based on interview, record review and observation the facility failed to ensure an approved process and training to follow recommendations established by the Association of Operating Room Nurses (AORN) for covering of the sterile table in 2 of 5 Operating Rooms. This deficient practice could lead to a break in the sterile process which could lead to infection for all patients receiving surgical services.

The findings are:

A. On 07/13/2022 at 9:20 am, in an interview with Staff S6, Director of Surgical Services, confirmed that "For covering sterile tables, AORN regulations changed in 2019 to say that as long as they are covered, then it does not need to be monitored."

B. On 07/13/2022 at 9:30 am, in an interview with S7, Nurse Manager of Surgical Services, confirmed "We follow AORN regulations ... If they break scrub [no longer comply with sterile technique], then they are to cover the tables."

C. Record review of AORN recommendations that the facility provided titled Guidelines for Perioperative Practice 2020 edition, on page 940, Sterile Technique states:
"Cover the sterile field with a sterile drape in a manner that allows the cover to be removed without compromising the sterility of the table. The sterile field may be covered with a sterile drape designed for this purpose or by the sterile two- "cuffed" -draped method described as follows:
Place the first drape horizontally over the table or other area to be covered, with the cuff at or just below the halfway point. Place the second drape from the opposite side of the table with the cuff positioned so that it completely covers the cuff of the first drape. Remove the drapes by placing the hands within the cuff of the top drape and lifting the drape up and away from the table and toward the person removing the drape. Remove the second drape from the opposite side in the same manner."

D. On 07/13/2022 at 1:24 pm, in an interview with S(staff)8, Surgical Scrub Tech, stated "Covering of the back table when you don't have eyes on is new for me. That's not what I learned in school. I learned that once that table is set up you don't take your eyes off it and you don't break scrub at all. But they said, that's how we do it here, it is based on AORN recommendations."

E. On 07/13/2022 at 1:33 pm, in an interview with S9, Surgical First Assistant Tech, when asked if they were trained in how to cover the back sterile table stated, "Not really, they just remind us in meetings. My concern would be that we haven't been taught how to uncover the table and keep it sterile. Especially with travelers [staff that do not work at the facility permanently]."

F. On 07/14/2022 at 7:09 am, in an interview with S12, Surgical Scrub Tech, when asked about covering of a sterile table and training regarding covering the sterile table stated, "We cover the table if we need to walk away from it ... Draping equipment is an overall technique so as long as you know that, then there is no need for special training."

G. On 07/14/2022 at 7:25 am, in an observation of Operating Room #5, after the sterile tables were set up, the 2 tables were observed in an L shape with 2 drapes on each table covered vertically with no cuff and no surgical scrub techs present. "

H. On 07/14/2022 at 7:30 am, in an observation of Operating Room #6, after the sterile back table was set up, the table was observed covered with 2 drapes vertically with no cuffs present and no surgical scrub techs present."

I. On 07/14/2022 at 6:27 am, in an interview with S10, Surgical Scrub Tech Traveler, when asked about covering a sterile table and training regarding covering the sterile table stated, "I was taught not to do that in school, I know they do it here, but I don't do it ... I already know how to do it, I just don't want to and yes they did offer me training, I just didn't do it [the training}."

J. On 07/14/2022 at 1:45 pm, in an interview with S4, Chief Nursing Officer, when asked about a training policy for surgical scrub staff to cover sterile tables stated, "I spoke with S6 [Director of Surgical Services] and he said that a draping method is universal for all equipment and we don't teach it just for covering the table."

K. On 07/14/2022 at 7:50 am, in an interview with S6, Director of Surgical Services, when asked about the AORN two- "cuffed" -draped method confirmed that the facility was not teaching the two- "cuffed" -draped method to surgical scrub techs and that although there were special drapes ordered that are made to cover the tables, they were not using that method either.