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Experts: Risk of disease transmission is very low

Hennepin County Medical Center in Minneapolis is notifying roughly 2,600 patients who had a specialized type of gastrointestinal procedure that a piece of the equipment used was not fully sterilized.

The patients, who had the procedure between June 11, 2007 and May 28, 2010, are being informed that while the instrument used for their procedure was fully cleaned with enzymatic detergent, a final disinfectant soak did not include one small channel in the scope. HCMC said it followed instructions from the disinfecting device manufacturer, but the information was incorrect.

The procedures in question used an endoscopic ultrasound to view and treat areas in a patient’s abdomen.

HCMC changed procedures for disinfecting endoscopes after discovering the discrepancy in the instructions and contacted the Minnesota Department of Health and the Food and Drug Administration.

This situation does not involve endoscopes used for more routine screenings and colonoscopies.

“ HCMC apologizes to the patients who had these procedures,” said Chief Nursing Officer Kathy Wilde, RN, MA. “While the risk to any of our patients is remote because the scopes were thoroughly cleaned, which is the most important step to eliminate germs, we chose to be extremely cautious by making our patients and the public aware of this incident.”

In addition to consulting with the state health department, HCMC also contacted the Centers for Disease Control and Prevention and several national experts in the field and was advised the risk of transmission of any disease to patients is very remote. Based on the remote risk, it was determined that there was no medical need to recommend specific testing, treatment or follow-up.

The endoscopes in question have several channels in them through which the doctor can insert or withdraw various instruments. Several steps are followed in cleaning and disinfecting endoscopes after every use. The standard procedure calls for the manual cleaning of each channel in the endoscope with an enzymatic detergent, followed by soaking all channels with disinfectant. After that, the channels are dried with forced air. In this situation, the entire endoscope was thoroughly cleaned with enzymatic detergent, but due to the instructional error regarding the use of a specific connector, the disinfectant solution did not reach one channel during the disinfecting process

Source: myfoxtwincities