CPE cluster linked to a screening colonoscopy unit

Patient safety and transmission control outrank the waiting list, but the answer is targeted, not a blanket shutdown.

1. Convene the incident management team - endoscopy clinical lead, infection prevention and control (IPC), microbiology, decontamination lead, screening programme, communications. One decision log, one spokesperson.
2. Notify the local IPC/AMRIC team and HPSC in line with national CPE reporting requirements; confirm with IPC whether notification applies to colonisation as well as infection, and notify the screening programme's quality function. Antimicrobial resistance organisms carry reporting duties - confirm the current requirement rather than assume.
3. Stop use of the affected reprocessor and the affected room until it is validated: service records, microbiological testing of final rinse water, filter checks, cycle log review. This is the one non-negotiable. A machine that has logged a final-rinse failure and been overridden is a plausible transmission route, and continuing lists converts a contained problem into an open one.
4. Protect urgent cases. Divert urgent and time-critical procedures to a validated room or a neighbouring unit; defer elective screening lists only as long as necessary. Document the clinical risk of deferral for each patient moved.
5. Fix the override culture immediately. Issue a standing instruction that a final-rinse alarm stops the list and is escalated, and check whether staff overrode because no escalation route existed at night or because of throughput pressure. That is a human factors finding, not a disciplinary one, until the facts say otherwise.
6. Care for the two patients - the man with the wound infection needs clinical management and open disclosure; the asymptomatic carrier needs clear explanation of what colonisation means.

Direction matters. You cannot yet say the unit infected these two people. One or both may have arrived already colonised, in which case the lookback is about finding anyone they exposed during procedures, not only about the reprocessor. Design the lookback to answer both questions.

Defining exposure: all patients who had a procedure in the affected room in the period covered by the failed cycles, plus a margin either side (the reprocessor may have been deteriorating before the alarm). Include patients whose procedure followed either index case. Record the exposure definition, the date range and why, because it will be scrutinised.

Case finding: cross-check the screening register for the window; offer CPE screening (rectal swab) to exposed patients; screen the unit's staff only if IPC advises it. Escalate any positive result to IPC and add it to the cluster case definition.

Communication: a letter from the programme, signed by a named clinician, with a same-day phone line. Content: we are reviewing infection control in the unit; you may have been exposed to a bacterium; most people who carry it have no symptoms and it clears, but it can cause infection in people who are frail or have devices; we are offering a simple swab test; here is what to do and who to call. Avoid blaming language and avoid false reassurance. Pre-brief GPs so they are not blindsided, and give them the same script.

Also: think about who is not in the screening register - patients who had procedures in the same room outside the screening programme - and make sure the hospital's own lookback covers them.

Restart is a governance decision with named sign-offs, not a judgement that 'things look better'.

• Reprocessor validation: engineer's service report, replacement of filters, microbiological testing of final rinse water with results inside accepted limits, and a clear statement of what the fault was.
• Process fix: a written standard operating procedure that a final-rinse alarm stops the list; an escalation route that works out of hours; a log that cannot be overridden without a named authoriser and a recorded reason; and evidence that staff have been trained on it and know they will be supported if they stop a list.
• Practice observation: direct observation of a full decontamination cycle by the decontamination lead, plus a sample audit of manually cleaned endoscopes for residue and channel condition.
• Sign-off: IPC consultant, decontamination lead and the screening programme's quality lead, recorded in writing with a date.
• Surveillance: enhanced CPE screening of patients for an agreed period after restart (for example three months) with a defined trigger for pausing again, and a report to the programme board and HPSC.
• Capacity honesty: if throughput pressure contributed to the overrides, restarting at the same volume with the same staffing recreates the conditions. The assurance must include a statement of safe capacity and a plan to meet the 900 waiting list without re-creating the pressure - additional sessions, a second machine, or revised scheduling.

I would also want the incident reviewed with a human-factors lens, not just a machine repair, because alarms are overridden in units where stopping feels more costly than carrying on.