Would You Be Scoped in Your Own Facility?
Tips and Tricks to Endoscope Reprocessing
by Nancy Schlossberg, BSN, RN, CGRN, CER, Program Director-Digestive Health Services, John Muir Health
New guidelines from the American Cancer Society recommend that colorectal cancer screening begin at a younger age than what is currently recommended. For persons at average risk, screening should begin at age 45 rather than 50, based in part on recent data demonstrating a rise in colorectal cancer among younger populations. Accordingly, hospital outpatient departments and ambulatory surgery centers might expect to schedule more patients for screening colonoscopy.
In my experience, patients coming for their screening colonoscopy are often very anxious, fearing the dreaded cancer diagnosis. As nurses, we need to reassure patients that screening saves lives.
Patients typically ask the following questions: How long does the procedure take? Does it hurt? When can I eat again and what? However, given the publicity about contaminated endoscopes, what patients really want to ask are: “How do I know my scope is clean? Do you sterilize your scopes? In fact, some patients would rather chance colon cancer than have a potentially life-saving colonoscopy!
My hope is to open discussion in regard to how you and your staff will provide reassurance that scopes are patient ready, and more so, would you and your staff be scoped in your own facility?
Consistently effective endoscope reprocessing and safety is a multidisciplinary effort. I believe that OR and endoscopy unit managers must proactively ensure communication and collaboration between clinical and reprocessing staff, infection prevention personnel, and management. When teamwork breaks down, the result could be contaminated endoscopes, which pose a significantly increased risk to patients.
Rule #1: Never assume! When and if a breach in reprocessing occurs, OR and endoscopy managers will be expected to know the location of the breach and produce all incident-related equipment Instructions for Use (IFUs) and repair histories, as well as the personnel training and education records of those involved.
Rule #2: Mitigate risk! Work with your team to concentrate on 10 “gotchas;” Manufacturer’s IFU; competency demonstration; sequence of reprocessing steps; pre-cleaning; delayed reprocessing; transporting endoscopes; cleaning verification; quality assurance; keeping up to date; and certification.
Here are some quick tips to live by:
- Manufacturer’s IFUs should reflect current endoscope inventory and be immediately accessible to front line reprocessing staff. Organize a scavenger hunt for all scopes and compare to IFUs available on file. Check drawers, shipping containers, and storage areas. Contact original equipment manufacturers or consider document management solutions like One Source to retrieve most recent IFUs. This is a good time to compare endoscope inventories to facility property ledgers and trade up, replace, or remove antiquated endoscopes.
- A group in-service demonstration and sign in sheet does not replace documented hands on return demonstration to validate competency for each individual reprocessing endoscopes for each model of endoscope in inventory. SGNA, AORN and AAMI recommend that reprocessing personnel demonstrate competency for all steps of endoscope reprocessing, including proper use of automatic endoscope reprocessor (AERs) and other equipment at least annually and for new models of endoscopes, accessories, valves, and AERs as soon as they are introduced into the facility. What does your institution’s policy and procedure require? Do you have the documentation that backs up your policy and procedure? Is it time to update your policy and procedure?
- Do not omit endoscope reprocessing steps. Perform the steps in the order that follows:
- Leak testing
- Manual cleaning
- Rinse after cleaning
- Visual inspection
- High-level disinfection
- Rinse after high-level disinfection
- Drying (alcohol and forced air)
It does no good to leak test a scope after manual cleaning! The damage may already be done. Omitting leak test may result in endoscope contamination and operational failure during a procedure.
- Pre-cleaning is the most commonly neglected but necessary step that requires validated demonstration of competency. Pre-cleaning removes gross soil immediately after point of use before bioburden has an opportunity to dry, before complete decontamination, and before the endoscope has been detached from the light source and processor. The extra minute or two for pre-cleaning should never be sacrificed for workflow and turn around efficiencies. Staff needs to remain mindful of dirty-to-clean flow of staff and equipment during pre-cleaning.
- When developing your reprocessing policy and procedure, refer to the manufacturer’s IFU for definitions and instructions for delayed reprocessing. Implement a system to document time between pre-cleaning and the start of manual cleaning as well as the time between completion of manual cleaning and high-level disinfection.
- After pre-cleaning, scopes should be transported to reprocessing areas in a closed container labeled to indicate biohazardous contents, which prevents exposing staff or the environment to potentially infectious organisms. Pillow cases and disposable under pads are not impervious to contaminated fluids. Use care with specially created single use endoscope transport pads or bags. They are not puncture proof. Also, pads wrapped too tightly may inadvertently damage endoscope insertion tubes and bending sections.
- It is impossible to visualize internal channels. Literature suggests that, to confirm the adequacy of manual cleaning, a rapid cleaning monitor (or rapid audit tool) for residual organic soil can be used before high-level disinfection. If the tool results are positive, this allows for re-cleaning of the endoscope before high level-disinfection. Therefore, tests for cleaning verification, such as ATP or other rapid tests for common organic soils including blood, protein, and carbohydrates, should not happen after the endoscope has been high-level disinfected!
- The continued safety and efficacy of endoscope reprocessing requires implementation of ongoing quality assurance processes. For reasons of traceability in the case of an outbreak, procedure documentation must include procedure date and time, patient’s name and/or medical number, endoscopist’s name, endoscope model and serial number or other identifier, AER serial number or other identifier, and the names of individuals who reprocessed the endoscope.
Standards of Infection Prevention in Reprocessing Flexible Gastrointestinal Endoscopes, (SGNA 2016) recommend other documentation essential for infection control should include information and audits about reprocessing activities, equipment performance and maintenance records, and records verifying that high-level disinfectants were tested and replaced appropriately. Audits should monitor all reprocessing steps and provide feedback to personnel regarding their adherence to cleaning and disinfection procedures (CDC, 2015).
- There is no excuse for OR and endoscopy managers not staying current with most recent manufacturer’s IFUs, as well as recommendations from professional societies, such as AORN, AAMI and SGNA, and governmental agencies, such as CDC and FDA. Consider the Infection Prevention Champion program designed to educate gastroenterology and endoscopy staff on infection prevention and control topics, maintaining high quality control within the endoscopy arena, and addressing performance improvement needs.
- Finally, hospitals and surgery centers dealing with high volumes of endoscopic procedures prefer to hire technicians certified in endoscope reprocessing. Currently, the Certifying Board for Sterile Processing and Distribution (CBSPD) offers the Certified Flexible Endoscope Reprocessor (CFER) exam, and The International Association of Healthcare Central Service Materiel Management (IAHCSMM) has developed the Certified Endoscope Reprocessor (CER) exam.
Remember, you or your loved one might be attached to the other end of the scope!
What have you done to ensure your facility is the place of choice?