DS 34 - Investigation of a Reprocessing Breach in an Ambulatory Care Clinic

Background: Reprocessing breaches can result in patient exposure to bloodborne pathogens. Infection Prevention was notified of a reprocessing breach at a suburban clinic that is part of a health system. Prior to steam sterilization, washed and wrapped unprocessed items were mistakenly restocked in exam rooms. Chemical indicators were inconsistently checked at the point of use, so it was possible that unprocessed items were used on patients.

Methods: A multidisciplinary response team was convened. The Centers for Disease Control and Prevention (CDC) framework for investigating an infection control breach was used to guide the investigation and indicated this was a breach with lower likelihood of blood exposure. The investigation timeframe was defined as the four-week period following a reprocessing workflow change.
Out of an abundance of caution and to align with a transparent, patient-centered approach, the team developed a plan for notifying patients that instruments used during their care were thoroughly cleaned but may not have undergone sterilization. Patients were offered testing at no charge for hepatitis B (HBV), hepatitis C (HCV) and human immunodeficiency virus (HIV). State public health and CDC communication teams assisted with content development for the patient notification. The team developed scripting and other resources to support nurse-patient communication. A system was developed for tracking notification, results and laboratory costs.

Results: Seventy-eight patients were notified of the reprocessing breach and offered testing. Twenty-three (29%) patients completed the recommended follow up testing. All 23 patients tested negative for HBV, HCV, and HIV. The laboratory costs of testing patients were $13,892. The estimated time to complete this investigation and response exceeded 200 hours.

Conclusions: Investigating reprocessing breaches is time and resource intensive. Engaging a multidisciplinary team and using CDC resources supported a patient-centered disclosure process. This event underscores the importance of infection prevention programs in ambulatory care to support best practices.