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Reducing the risk of cross-contamination from transmissible spongiform encephalopathies

AORN Journal, Sept, 2005 by Timothy A. Brendle

In response to recent reports from several major US medical centers regarding possible exposure of surgical patients to the virulent class of diseases known as transmissible spongiform encephalopathies (TSEs), (1,2) one institution developed guidelines to care for surgical patients with a preoperative diagnosis of "rule out TSE." The guidelines not only protect patients from accidental exposure to TSE, but they also protect nurses, surgeons, technologists, anesthesia care providers, housekeeping personnel, and sterile processing department staff members.

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Transmissible spongiform encephalopathies is a catchall term for several prionic diseases, including bovine spongiform encephalopathy (ie, mad cow disease), Creutzfeldt-Jakob disease (CJD), variant CJD, and Gerstmenn-Straussler-Scheinker syndrome. Prions are proteins that attack the brain of humans and some animals and cause an array of neurological symptoms, including sleep pattern changes, fatigue, memory loss leading to presenile dementia, and, ultimately, death. (3,4) There are three theories related to how a TSE infection is contracted. Sporadic infections have no discernible cause or apparent origin. (5) Inherited infections (ie, in which there is a family history of the disease) account for about 10% to 15% of reported cases) Iatrogenic transmission (ie, exposure via a medical procedure or cross-contamination from contaminated surgical instruments) (5) is the focus of this article.

THE CASE FOR DISPOSABLE INSTRUMENTS

Recently reported incidents of surgical patients' possible exposure to TSE seem to share a common denominator--reused surgical instruments. (1,2) Prions have a high tolerance for current sterilization methods, including heat, chemicals, gas, and ionizing radiation. (6) Disinfectants and some tissue fixatives also have little effect on prions. (6)

Institutions that use "CJD-only" instruments and drills may present a threat to surgical patients as well. There is a risk that these instruments accidentally could be used on the wrong patient or be sterilized in the same autoclave cycle as other surgical instruments. Another risk is the possibility of using CJD-only instruments on a patient with a preoperative diagnosis of "rule out TSE," only to find that the pathology is benign. Now the patient may have been exposed inadvertently to TSE.

One solution to reduce the possibility of cross-contamination during surgical procedures on patients suspected of having TSE is to use disposable surgical instruments. (7,8) Some people will say that using disposable instruments is not cost effective or practical; depending on surgical need and the instrument company, a disposable CJD instrument tray could cost between $1,500 and $2,300. Others would argue, however, that reducing the real risk of iatrogenic transmission to a surgical patient should far outweigh this cost. Use of disposable instruments also reduces the number of personnel who could be exposed to infectious material.

ONE FACILITY'S TSE GUIDELINES

Staff members at one facility formulated a TSE/CJD policy in part following the guidelines set forth by the University of Iowa Hospitals and Clinics. (9) Criteria for performing a biopsy to rule out TSE usually are related to the presentation of specific symptoms or positive results of diagnostic tests. Symptoms that may indicate TSE include, but are not limited to,

* presenile dementia,

* myoclonus,

* electroencephalogram changes indicative of TSEs,

* cerebral spinal fluid protein elevation 14-3-3, and

* basal ganglia changes noted via magnetic resonance imaging scan. (4)

When a surgical patient presents with some or all of these symptoms, it is imperative that the surgeon inform the OR scheduler and infection control department personnel of the suspected diagnosis. Unless clinicians communicate with one another, no policy, standard of care, or state-of-the-art computerized scheduling system will be effective against future exposure of surgical patients to TSE.

This facility uses a computerized scheduling system that has a set of specific codes based on the posted procedure. If a surgeon schedules a patient for brain biopsy to rule out TSE, the code generated (ie, BRNBXCJD) is programmed to produce a warning message to the scheduler to initiate TSE protocols and precautions.

PREOPERATIVE. A procedure to rule out TSE is scheduled as the last procedure of the day or as the only procedure in a selected OR suite. The OR is stripped to a bare minimum of equipment and sup plies. Equipment should be limited to an anesthesia machine, OR bed, suction machine, electro-surgical trait, and back table. All trash cans are removed, with the exception of one biohazard receptacle and a sharps box. A large, disposable, impervious drape sheet is placed in the center of the room and taped in place, and the OR bed is centered on the sheet. The sheet helps contain any infectious material. The bipolar foot pedal cord is covered with a plastic bag, which extends at least 4 ft from the pedal and is taped in place. Each end of the OR bed is covered with impervious biohazard plastic bags and covered with a sheet (Figure 1). Anesthesia care providers are reminded to use only disposable supplies for intubation and ventilation.

Health Care Industry

Reducing the risk of cross-contamination from transmissible spongiform encephalopathies

AORN Journal, Sept, 2005 by Timothy A. Brendle

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