METHODS: Reprocessing lapses were identified during a regulatory inspection of 40 ambulatory clinics under the license of a regional hospital. Risk of transmission of blood borne pathogens (BBP) from reusable medical equipment was assessed by public health via interviews and discussion with hospital staff, infection prevention and infectious disease experts, and staff from US Centers for Disease Control and Prevention. A standardized questionnaire was used to detail specific reprocessing practices in each of 22 clinics that perform in-office procedures with reusable medical equipment and risk stratification was applied to identify which clinics and procedures warranted patient notification. Risk categories were: “No risk identified”; “Negligible risk”, value of transparency deemed to not outweigh potential harms of patient notification; “Very low risk”, recommend patient notification with offer of BBP testing; or “Low risk”, recommend patient notification with offer of BBP testing and cross match of patient names with DOH BBP databases.
RESULTS: Of the 22 clinics interviewed, 5 clinics had inadequacies in reprocessing that were deemed by public health to warrant patient notification. Notification was sent to 253 clinic patients who had procedures thought to confer risk. There were no matches of patient names with cases in the state BBP database. Eighty-one patients were tested for BBP with no positive results. The investigation, closely following another large patient notification event in the state, attracted local and national media attention.
CONCLUSIONS: Reprocessing of reusable medical equipment is complex and requires assiduous attention to each step in order to prevent transmission of infections between patients. Inadequacies in cleaning, disinfection and sterilization require scrutiny to determine whether a lapse warrants patient notification. Multiple factors must be carefully considered in these situations, including patient population, quality of documentation of medical and quality assurance records, resources for review of medical records, the facility’s cooperation with public health, and likelihood of media attention. We present a brief summary of the investigation and how the risk stratification was applied to determine which patient should be notified.