4 Major Updates to Improve Flexible Endoscope Safety

The steady stream of new research on safer practices for processing flexible endoscopes has led to new evidence-based practices AORN now recommends in the newly revised Guideline for Processing Flexible Endoscopes that just published electronically. Updates include a stronger position on borescope inspection, recommendations for hand-over communication to decontamination personnel, and information about pre-purchase evaluation of single-use and reusable flexible endoscopes.

Periop Today spoke with our own Senior Perioperative Practice Specialist Amber Wood, MSN RN CNOR CIC FAPIC, to understand how the updated recommendations she authored will change practice. She also gave us some helpful tips to implement these new practices into existing processing workflows.

Zeroing-In on a Narrow Margin of Safety

“We know flexible endoscopes are associated with far more outbreaks than any other medical or surgical device—these complex medical devices require equally complex processes for effective cleaning and sterilization or high-level disinfection (HLD),” Wood stresses.

While there are many updates in the revised guideline to review, she suggests starting with these four major practice changes to help teams fall within the narrow margin for safety when processing flexible endoscopes.

1. Refine the hand-over process from the transporter to decontamination personnel.

See Recommendation 6.7

Direct communication and documentation should include the time that the point-of-use treatment was complete and whether the endoscope was exposed to factors during the procedure that may require additional cleaning, such as simethicone, radiographic mediums, lubricants, tissue adhesives, poor bowel preparation, or increased blood loss, Wood explains.

2. Use a clean borescope to visually inspect accessible channels of flexible endoscopes before sterilization or HLD.

See Recommendation 9.4

Borescopes allow for visual inspection of internal channels and may identify damage or debris that would otherwise be undetected. Wood says inspection of cleaned flexible endoscopes with a borescope “is a critically important action that should be performed by competent personnel as part of a comprehensive visual inspection and cleaning verification program.”

3. Use cleaning verification tests to verify manual cleaning of flexible endoscopes before sterilization or HLD.

See Recommendation 9.5

Cleaning efficacy has traditionally been evaluated visually; however, “visual inspection alone, even with magnification, is not sufficient to determine cleanliness of complex devices such as flexible endoscopes,” Wood says. Cleaning verification testing such as with ATP, protein, carbohydrate, or hemoglobin is recommended to provide an objective method for verifying cleanliness.

4. Dry all accessible channels of HLD-processed flexible endoscopes in accordance with the manufacturer’s IFU with pressure-regulated instrument air or HEPA-filtered air for a minimum of 10 minutes or until no visible moisture remains.

See Recommendations 12.1, 12.5, 12.5.3

“Lack of compliance with drying processed endoscopes is a widespread problem that is often overlooked,” Wood cautions. “Any moisture remaining on the exterior and interior surfaces of the endoscope can facilitate microbial growth and biofilm formation during storage.”

Implementing Safer Flexible Endoscope Processing

To develop an implementation plan, Wood suggests looking to the AORN Guideline Implementation Road Map. “Use this tool to walk through implementation steps, beginning with a gap analysis of the revised guideline and your facility’s current policy and procedures.” Policy revision will likely be needed after performing a gap analysis because of the number of changes in this guideline update, especially around borescope inspection, which is likely to be the most challenging change in practice.

“Borescope inspection should not be implemented on its own—it should be part of a comprehensive visual inspection and cleaning verification testing program,” she advises. “Start small and expand the borescope program as you work out the kinks.” For example, limit the frequency of inspection, who performs inspection, and prioritize the highest risk endoscopes, such as duodenoscopes, bronchoscopes, and cystoscopes.