Does owning an automated endoscope reprocessor mean you can skip manual cleaning? Sorry. The answer is no. "Reprocessing starts in the procedure room," says Jim Collins, BS, RN, CNOR, practice manager for the department of gastroenterology and hepatology at the Cleveland Clinic and chairman of the education committee for the Society of Gastroenterology Nurses and Associates.

Before your techs can attach a scope to an automated reprocessor, close the lid and let the machine do its work, they still need to wipe the scope down as soon as possible after leaving the patient. You can't skip this bedside cleaning step, even if you're using Advanced Sterilization's Evotech, the only automated reprocessor that has been approved for use without manual cleaning with a brush (see "A Sampling of Automated Endoscope Reprocessors" on page 84).

Start early, every time
At the Cleveland Clinic's busy GI department, techs reprocess about 80 scopes a day using Evotech. "I'm getting good results," says Mr. Collins. But there are still drawbacks. The machine isn't validated for all scopes used in gastroenterology. "There's not an ideal scope washer out there yet," he says.

With all other automated endoscope reprocessors, your techs need to perform the bedside wipedown to get rid of any tissue or body fluids and then perform all the steps of manual cleaning — flushing, brushing and leak testing — before connecting the endoscope to the automated reprocessor, say reprocessing experts.

Having to manually clean before using an automated reprocessor is not necessarily a bad thing. "I like the fact that you're doing a second wash," says Beth Buckley, BSN, RN, director of nursing at the South Hills Endoscopy Center in Upper Saint Clair, Pa., where the reprocessing department uses an automated ultrasonic endoscope reprocessor. Ms. Buckley says that the benefits of the automated system are the fact that the machine can clean and disinfect 2 scopes at a time and that the standardized cycle time lets the techs do other tasks while it's running.

Other endoscopy managers like the fact that some automated reprocessors don't reuse cleaning and disinfecting solutions, although this adds to the per-cycle cost.

Why all the confusion?
When automated scope reprocessors first came on the market, sales reps suggested that the machines were analogous to dishwashers and that there would be no need to manually clean scopes anymore. "That's the way they marketed them in the beginning," says Gail Greco-Bieri, an educator for Spectrum Health in Grand Rapids, Mich., who has taught reprocessing courses for the SGNA.

Since then, the FDA, the ASGE and the SGNA have made clear their positions on the issue. For example, regardless of whether the reprocessing equipment is approved for use without manual cleaning, the SGNA still recommends manual cleaning. "It is necessary to follow all steps for the manual cleaning of the endoscope prior to using an automated reprocessor. No independent confirmatory data are currently available to show that automated preprocessors are able to provide cleaning of endoscopes that is comparable to that of manual washing and brushing," states the society in its 2009 Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes. But in some facilities the misconception continues, says Ms. Greco-Bieri.

New evidence
The data on the efficacy of using an automated reprocessor without manual cleaning has just begun to come in. In an article published in the July issue of BMC Infectious Diseases, researchers from the University of Manitoba, Winnipeg, report that an automated endoscope cleaner and reprocessor removed 98.8% of the bioburden (protein, hemoglobin and other residuals) from endoscope surfaces and 99.7% from the lumens of 75 endoscopes used on patients. (The study was funded by Johnson & Johnson's Advanced Sterilization Products, the makers of the automated system used in the study.) Compared to an 80-week Australian study reported in the June 2006 issue of the American Journal of Infection Control, the automated system did a slightly better job of cleaning than humans, who removed 98.2% of the bioburden from gastroscopes and 98.1% of the bioburden from colonoscopes.

Leak testing
Regardless of whether you use an automated reprocessor, you shouldn't skip certain steps during the manual phase of reprocessing. After the initial wipedown, the next step is leak testing.

A leak from a crack or broken seal can let moisture reach electronic components of the endoscope or create a foggy image. To prevent this, it's important to check for leaks during each reprocessing. Some automated machines do this, but still many facilities leak check by hand using an electric pump that forces air into the sealed endoscope. Once the endoscope is connected to the pump, submerge it in water and enzymatic cleaner and look for bubbles. The solution should be clear enough to see the bubbles. Make sure that the whole scope, including the handle, is submerged.

Many techs don't take the time to manipulate the scope. "Like when the doctor has it hooked up to the screen," says Robert A. Montano, CRCST, supervisor of sterile processing at the Vail Valley Medical Center in Vail, Colo. Manipu-lating the scope in various articulations will help you find any cracks that might not be evident when the scope is not bent in a certain manner, says Mr. Montano.

Leak testing takes 4 to 7 minutes, but it's very important in helping to prolong the life of your scopes. If you do find a leak, wipe down the scope with disinfectant and send it to the manufacturer for repair, says Mr. Montano.

Brush right
Before you flush the scope the tech should run a small brush into the biopsy lumen and the suction channel. Usually each channel requires a different size brush and it's important to use the size and type of brush recommended by the manufacturer, says Mr. Montano.

Pushing the brush into the biopsy lumen pushes any gross contaminants into the main channel of the scope, where they'll be flushed. It takes a bit of time, but brushing the lumens gets rid of solids that the machine might not be able to get. "These 2 minutes are very important," says Mr. Montano.

The importance of training
Regardless of the system that you use, having properly trained reprocessing techs will improve safety and efficiency. Accreditors and CMS inspectors are paying more attention to training during their visits, says Andrew Weiss, CASC, administrator at the Endo Center at Voorhees in New Jersey. "That's what Medicare is looking for." At Mr. Weiss' facility, techs receive training through the scope manufacturer as well as the SGNA and work to receive the Advanced GI Technical Specialist certification (www.sgna.org/education/associates.cfm).

The better trained your employees are, the more ownership they'll take in the process of cleaning and disinfecting scopes, says Ms. Buckley. The result will be better consistency and handling of the scopes, which will help the devices last longer.

It's not just a matter of putting the scope in the machine. You need to use your hands and your eyes, says Ms. Buckley. "Everyone has to know that this is the first part of cleaning."