The use of flexible endoscopes for endoscopic retrograde cholangiopancreatography (ERCP) is increasing as it represents a relatively non-invasive method for the diagnosis and treatment of certain conditions of the biliary and pancreatic ductal systems, such as gallstones, undefined biliary strictures, bile duct injury or leaks, and cancer. The design of duodenoscopes, however, is complex; they have long narrow channels and a recessed elevator at the distal end that enables good use of any accessories. All the external surfaces and internal channels are in contact with body fluids, presenting a risk of contamination and transmission of infection from patient to patient as well as from patient to endoscopy personnel. As these flexible devices are heat labile and not suitable for steam sterilization, careful cleaning (reprocessing) is needed to minimize the risk of contamination.

A recent event on Hygiene Solutions in Endoscopy was held at PENTAX Medical R&D Center (October 2019, Augsburg, Germany) to discuss insights on the need for infection control and how to minimize contamination. The event brought together a number of key opinion leaders in the field of ERCP hygiene (endoscopists, microbiologists and chief nurses) and included Paul Caesar, Hygiene and Infection Prevention expert at the Tjongerschans Hospital (Heerenveen, The Netherlands), Dr Hudson Garrett Jr., Global Chief Clinical Officer at PENTAX Medical and Assistant Professor of Medicine (Division of Infectious Diseases) at the University of Louisville School of Medicine, Kentucky, USA, as well as Wolfgang Mayer, Managing Director of Digital Endoscopy at PENTAX Medical.

Endoscopy-associated infection
The healthcare community is increasingly aware of the risk of hospital-acquired infection associated with endoscopy following documentation of several outbreaks of patient infections linked to duodenoscopes in the USA and around the world in the last decade as well as regulatory recalls. However, Paul Caesar made the point that in reality there is very little data regarding infection rates. One of the issues is that patients are discharged from hospital more and more quickly following procedures. Then, if any infection subsequently develops, the patient usually attends their local general practitioner and the link to the endoscopy is not made. The point was made that currently no surveillance is done for post-endoscopy infection and this should be put into place to generate reliable data on infection rates.

Endoscope reprocessing
The role of endoscope reprocessing is crucial for mitigating the risk of infection and is achieved by mechanical cleaning detergent cleaning, high level disinfection, and rinsing and drying (Figs 1–3). However, research shows that in 45% of cases key reprocessing steps are skipped. Additionally, 75% of the reprocessing staff reported time pressures and non-compliance with guidelines related to reprocessing as a result. Paul Caesar emphasized this point saying, “Manual cleaning is still the most important step in reprocessing. However, in daily practice this stage is often downgraded to just a simple flush and brush. I call upon the field, to shift from reprocessing quantity to quality”. Another crucial step is to ensure that the device is thoroughly dried before storage. This reduces the risk of biofilm formation and bacterial growth. However, there are currently no official guidelines for the optimum drying time; even within Europe alone different countries use different drying times.

Suggestions for the improvement of reprocessing included:
1. proper explanation to and understanding by staff of the importance of the reprocessing stages to gain their commitment to following the procedure fully;
2. use of shorter visual pictogram explanations of the reprocessing stages rather than manuals that are approximately 150 pages long and are too complicated to thoroughly read and understand; and
3. traceability and tagging of the people performing the various tasks so that all the steps can be scanned and shown to be done in an optimal fashion.

Improving duodenoscope design
According to Calderwood et al., patient-to-patient transmission of infection has been linked to the elevator channel endoscopes (such as duodenoscopes) and attributed to persistent contamination of the elevator mechanism, the elevator cable and the cable channel. One solution to infection control is to use disposable duodenoscopes. However, this is not practical for every endoscopy because of the cost and the environmental impact. The one-time use of a disposable device is therefore recommended only for high-risk patients.

Hudson Garrett confirmed the company’s commitment to minimizing infection outbreaks with careful consideration of advice and requirements from the CDC (Centers for Disease Control and Prevention) and FDA (U.S. Food and Drug Administration) in the USA, and “using integrated feedback from all clinical stakeholders, optimizing reprocessing processes, and innovating products to directly tackle patient safety and infection prevention needs”. This has led to the development of a duodenoscope with a disposable distal cap with integrated elevator, hence eliminating the part of the device that is most associated with contamination. Additionally, use of the company’s dedicated dryer helps to ensure the device is fully dry, reducing the risk of microbial growth and subsequent potential contamination that can result from moisture. PENTAX Medical also has a strong commitment to the training of reprocessing staff, which (according to current data) requires a minimum of 8 hours to be done properly.

Hospitals have evolved considerably over the years from the early Greek temples of healing, asclepeia, to the large dark, cramped multiple-patient wards of the early Western hospitals, essentially for those who could not afford private care at home, and the brighter, more open smaller ward or single room hospitals of today. These changes have come about as medicine has advanced, technology has progressed and societal and patient conditions and demands have changed. It is difficult to predict how the hospital of tomorrow will look with any precision, but we can make some fairly accurate suggestions based on current trends and developments.

by Prof Jean-Louis Vincent

One key change is that intensive care unit (ICU) patients will represent an increasingly large proportion of hospital patients in the future. There are several reasons for this. First, improved disease prevention and primary care, shorter post-surgery hospital stays and facilitated home care will mean that patients who are hospitalized will be more seriously ill than at present and more likely to need intensive care. Another reason for the increased need for ICU beds is prolonged life expectancy. Improved healthcare means that the average age of the population is increasing worldwide, and older patients are more likely to have multiple comorbidities and to develop complex acute illness. In one report from the US, the number of hospital beds decreased by 2.2% while ICU beds increased by 17.8% over a 10-year period.

As such, the hospital of the future will be composed of a large number of ICU beds with relatively few hospital beds (other than daycare) for other patients (see figure). The ICU may be a physical unit at a strategic place within the hospital, or it may be a more “virtual” ICU with beds dispersed around the hospital. It is possible that in the future all hospital beds will have the potential to be an ICU bed, limiting the need for patient transfers between wards and reducing the time for key ICU interventions to be put into place when a patient is identified as deteriorating. This could also reduce any problems associated with ICU bed shortages. The potential limitations of such an approach include the need for all nursing staff to be trained in intensive care.

So, assuming that the physical ICU structure remains, at least for the near future, what will it look like? With current patient demands for privacy and problems associated with multiresistant pathogens, the ICU will almost certainly consist of multiple single rooms. These rooms will be large and spacious with easy access to the bed from all sides and room for relatives to visit and stay and for the patient to mobilize when possible. The rooms will have large interactive screens with access to patient results and monitored parameters, the ability to call and speak to healthcare staff via telemedicine, and of course standard entertainment channels. Because almost all monitoring, of hemodynamic parameters as well as laboratory values, will be non-invasive and results transmitted to the doctor’s smartphone and to central remote monitoring hubs by wireless technology, there will be much less visible equipment, cables and tubes. What equipment is still necessary will be much smaller, less cumbersome and more user-friendly than at present. Continuous monitoring, multiple feedback systems and computerized interrogation across multiple systems and disciplines will make ICUs much safer with fewer iatrogenic errors.

Visiting hours will be unrestricted throughout the hospital, including in the ICU, and family members, including children, will be welcome. This open access and greater involvement will impact positively on patients and on their families, reducing anxiety and helping to reduce post-ICU stress.

The hospital as a whole will be much more technology oriented than at present and interactive screens will be responsible for much of the routine administration with robots involved in basic services, such as delivery of food and medication, as well as patient mobilization and social stimulation. Care will be more patient-centered and personalized and the flow from home to general ward to ICU will be much more of a continuum. Indeed, some patients may be discharged directly home from the ICU, an option facilitated by continued surveillance using telemedicine. Patients and healthcare staff will have continuous and real-time access to patient medical results and data. Such data will be fed automatically into large international databases to help continuously improve patient management. This process will have become routine and current issues related to data privacy will no longer be a problem.
There will be fewer medical and nursing staff physically present on the wards as telemedicine will be more widely used, enabling remote control of drug infusions and other interventions and e-consultations at the request of the physician or patient. Although healthcare staff may therefore be seen less frequently, they will actually be able to spend more quality time talking to patients and their families.

Technological advances are changing how the world around us operates and the hospital is no exception. Future hospital and ICU design needs to provide flexibility and adaptability to continued technological developments. Healthcare workers and patients will need time to adapt to these changes and to learn how best to use them to improve care and outcomes. We must all be involved in developing the ICU of the future. As Abraham Lincoln said, “The best way to predict the future is to create it”.

Suggested reading:
1. Vincent JL. Critical care–where have we been and where are we going? Crit Care 2013;17 Suppl 1:S2.
2. Halpern NA, Goldman DA, Tan KS et al. Trends in critical care beds and use among population groups and Medicare and Medicaid beneficiaries in the United States: 2000-2010. Crit Care Med 2016;44:1490-1499.
3. Ewbank L, Thompson J, McKenna H: NHS hospital bed numbers: past, present, future. https://www kingsfund org uk/publications/nhs-hospital-bed-numbers#hospital-beds-in-england-and-abroad.
4. Vincent JL, Creteur J. The hospital of tomorrow in 10 points. Crit Care 2017;21:93.
5. Vincent JL, Michard F, Saugel B. Intensive care medicine in 2050: towards critical care without central lines. Intensive Care Med 2018;44:922-924.
6.Denis K, Bidet F, Egault J et al. Utilization of Robo-K for improving walking and balance in patients affected by neurological injuries: A preliminary study. Ann Phys Rehabil Med 2016;59S:e88.
7. Bailly S, Meyfroidt G, Timsit JF. What’s new in ICU in 2050: big data and machine learning. Intensive Care Med 2018; 44:1524-1527.
8.Michard F, Pinsky MR, Vincent JL. Intensive care medicine in 2050: NEWS for hemodynamic monitoring. Intensive Care Med 2017;43:440-442.

The author
Jean-Louis Vincent, MD, PhD
Dept of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium