Creutzfeldt-Jakob Disease Operating Room Protocols: Turning Published Recommendations into Reality

Abstract ISSUE: In 2001, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a sentinel event alert on the dangers of Creutzfeldt-Jakob Disease (CJD) after reports of incidents where exposure to patients may have occurred via instruments used during brain surgeries. Because of this alert, the University of Michigan Hospitals and Health Centers' CJD Operating Room (OR) policies and procedures were targeted for review. PROJECT: In early 2002, a group was formed representing neurology, neurosurgery, pathology, risk management, infection control, and operating room staff. The goals were to: • develop a protocol to identify potential CJD patients • develop exclusion criteria to appropriately narrow CJD precautions in the OR without increasing the risk of missing CJD cases • review and incorporate Centers for Disease Control and Prevention (CDC)/World Health Organization (WHO) sterilization recommendations • Evaluate and institute procedures promoting safe, user-friendly, and cost-effective care in the OR. RESULTS: The group developed exclusion criteria for brain biopsy and determined that CJD precautions are necessary in an adult receiving a diagnostic biopsy unless there is a: • space-occupying tumor or mass lesion • suspicious white-matter lesion • meningeal biopsy • pleocytosis on LP. Patients meeting the above criteria receive a neurology consult prior to brain biopsy. The neurologist is responsible for ensuring and documenting that all appropriate tests, as well as history and physical, are consistent with the possibility of CJD. The Operating Room now has: • a kit for rule-out CJD cases containing cleaning solutions, personal protective equipment, room signage, pre-printed labels for specimens and waste, duct tape, and a policy binder • disposable instrument trays for biopsies • a Web-based OR scheduling system that demands a selection of either “brain biopsy with CJD precautions” or “brain biopsy without CJD precautions” • a requirement for a neurology consult prior to brain biopsy. LESSONS LEARNED: Interdisciplinary consensus and review of OR policies and procedures resulted in consistent identification of patients with a possible diagnosis of CJD. It also enabled the OR to select items used for rule-out CJD patients and dispose of them in a safe and cost-effective manner.