Gastrointestinal Endoscopes: Frequency of Improper Cleaning Interview with:
Cori L. Ofstead, MSPH
President and CEO
400 Selby Avenue, Suite V |Blair Arcade West
Saint Paul, MN 55102-4520 What are the main findings of the study?

Dr. Ofstead: Our researchers found evidence that endoscope reprocessing lapses, which involved a failure to properly clean and disinfect endoscopes after patient use, were very common.  These lapses occurred in hospitals, clinics, and ambulatory surgery centers, and involved various steps of the process.  In many cases, the reprocessing problems persisted for months or years before being discovered. Over the past several years, thousands of patients have been exposed to contaminated endoscopes, which had significant implications for both patients and their medical providers. For example, we found quite a few cases where exposed patients had to be notified that proper procedures were not followed.  In some cases, testing confirmed transmission of pathogens with an increase in morbidity and mortality. Were any of the findings unexpected?

Dr. Ofstead: Although reprocessing lapses were very common and several of the incidents involved the exposure of numerous patients to contaminated endoscopes, only one report appeared in a peer-reviewed journal.  Our discovery that these lapses went unnoticed for so long was unexpected, too. What should clinicians and patients take away from your report?

Dr. Ofstead: Clinicians should make sure their institutions have developed policies and procedures to ensure the endoscopes they use are properly cleaned and disinfected after each use. Facilities should conduct routine monitoring to evaluate the effectiveness of their processes with regard to contaminant removal.  Patients who are notified of exposure to a contaminated endoscope should speak with their physicians about the testing needed to determine whether they have acquired a blood-borne virus or any other pathogens that can colonize the gut and cause problems later. What recommendations do you have for future research as a result of this study?

Dr. Ofstead: Epidemiologic investigations are needed to evaluate the impact of reprocessing practices on patient outcomes. Research is also needed to determine whether current reprocessing guidelines and policies are adequate to ensure patient safety.


Reported gastrointestinal endoscope reprocessing lapses: The tip of the iceberg
Alexandra M. Dirlam Langlay, Cori L. Ofstead, Natalie J. Mueller, Pritish K. Tosh, Todd H. Baron, Harry P. Wetzler
AJIC: American Journal of Infection Control – 09 September 2013 (10.1016/j.ajic.2013.04.022)