Emergency Department POCUS a New Frontier

Be aware of ultrasound probe cross-infection risks

Point-of-care ultrasound (POCUS) has become a cornerstone in the diagnosis and treatment of patients in the emergency and critical care departments.

To achieve the full ultrasound benefits in patient care, medical teams need to consider the contamination risk over repeated use of probes as a vector for pathogen transmission. Ultrasound probes are used for various applications and based on the level of infection risk probes are classified by the Spaulding Classification, as non-critical (low risk), semi-critical (medium risk) and critical (high risk). The classification also determines the probe disinfection level – Low Level Disinfection, High Level Disinfection, Sterilisation.1-4

The ultrasound probe can be compromised by contamination in various ways, allowing the probe to be a vector for pathogen transmission from patient procedure site, probe cover microtears, poor aseptic technique or contaminated gel. These common contamination risks can be transferred to the next patient. In a recent outbreak of Burkholderia cepacia bacteraemia in a tertiary care centre resulted from contaminated ultrasound probe gel. The B. cepacia was isolated from the blood cultures of 14 patients resulting from contamination of the gel applied to the ultrasound probe used to guide the insertion of a central venous catheter.4-6 This case clearly demonstrates that contaminated gel can lead to infections, but also highlight that a probe can be a vector for pathogen transmission.

 

In a study that examined ultrasound equipment used in five emergency departments and five intensive care units, 61% of samples tested positive for blood contamination and 48% tested positive for microbiological contamination. Of the items in direct patient contact, 14 of 16 (88%) transducer leads (cable) and 21 of 37 (57%) transducers showed blood contamination. Ten of 16 transducer leads (62%) and 17 of 37 transducers (46%) showed microbial contamination.7

The organisms identified included:

  • Gram-negative bacilli (Enterobacter, Klebsiella, Pantoea, Raoultella, Pseudomonas, Acinetobacter, Proteobacteriaand Aeromonas)

  • Gram-positive cocci (Staphylococcus, Enterococcus and Micrococcus)

Medical staff need to know how to effectively reprocess an ultrasound probe prior to use on the next patient. Further, reduce the risk for infection and colonisation using evidence-based aseptic technique that diminish the entry of endogenous or exogenous organisms via invasive medical devices.2,3,8

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References:

1. Shokoohi HA, Armstrong P, Tansek R. Emergency department ultrasound probe infection control: Challenges and solutions. Open Access Emergency Medicine. 2015;7:1-9. 5. 2. Keys M, Sim BZ, Thom Ogilvie, et al. Efforts to Attenuate the Spread of Infection (EASI): a prospective, observational multicentre survey of ultrasound equipment in Australian emergency departments and intensive care units. Crit Care Resusc. 2015;17(1): 43-46. 3. Hughes et.al (2008) Preventing Health Care–Associated Infections: Advances in Patient Safety and Quality: An Evidence-Based Handbook. Rockville (MD): Agency for Healthcare Research and Quality (US); Apr. Chapter 41. 4. Abdelfattah R. et al. (2018) Outbreak of Burkholderia cepacia bacteraemia in a tertiary care centre due to contaminated ultrasound probe gel. J Hosp Infect. 2018 Mar;98(3):289-294. doi: 10.1016/j.jhin.2017.09.010. Epub 2017 Sep 18. 5. Shaban RZ, Maloney S, Gerrard J, Collignon P, et al. Outbreak of health care-associated Burkholderia cenocepacia bacteremia and infection attributed to contaminated sterile gel used for central line insertion under ultrasound guidance and other procedures. American Journal of Infection Control. 2017; pii: S0196-6553(17)30843-X. 6. Therapeutic Goods Administration (TGA). Meditech Ultrasound Gel: safety Advisory – Risk of Bacterial Contamination. Safety Information – Alerts. 2017. Available from: https://www.tga.gov.au/alert/meditech-ultrasound-gel. 7. Keys M, Sim BZ, Thom Ogilvie, et al. Efforts to Attenuate the Spread of Infection (EASI): a prospective, observational multicentre survey of ultrasound equipment in Australian emergency departments and intensive care units. Crit Care Resusc. 2015;17(1): 43-46. 8. Entesari-Tatafi D, Orford N, Bailey MJ, Chonghaile MN, LambJenkins J, Athan E. Effectiveness of a care bundle to reduce central line-associated bloodstream infections. Med J Aust 2015; 202: 247–50. 9. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 Electronically accessed: http://www.cdc.gov/ nchs/data/nvsr/nvsr61/nvsr61_04.pdf, June 2014. 10. Scott, RD. The Direct Medical Costs of Healthcare-Acquired Infections in US Hospitals and the Benefits of Prevention, Centers for Disease Control and Prevention. 1–13, 2009.

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