No More Dirty Endoscopes

Gastroenterology

By: James Collins

Published: 1/16/2019

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Enhance the performance of your reprocessing team and reduce the likelihood of human errors that could impact patient safety.


IMPORTANT JOB Contaminated endoscopes introduce microorganisms to a patient's GI tract that spread to adjacent tissue or organs.   |  Pamela Bevelhymer, RN, BSN, CNOR

Endoscopes are complex instruments with complex reprocessing requirements, but cross-contamination risks during GI procedures are minimal, right? Not necessarily. A recent Johns Hopkins study showed that infection rates within a week of upper endoscopies and colonoscopies performed at some ambulatory surgical centers were 100 times higher than previously believed. The infection rate of a routine colonoscopy was thought to be somewhere in the neighborhood of 1 in a million. According to the study, however, the rate is actually closer to 1 in 1,000.

Surgery center staffs are often unaware that their patients suffer serious infections after they leave their facilities, says study author Susan Hutfless, PhD, SM, an assistant professor of medicine at Johns Hopkins. Ignorance might be bliss, but Dr. Hutfless points out that in this case it’s preventing surgery center administrators from being motivated to improve their infection control practices. The following steps will prevent you from being lulled into the same false sense of security about the cleanliness of your endoscopes.

1. Perform spot checks

Adenosine triphosphate (ATP) testing can be invaluable in helping your reprocessing techs monitor how well they brush and flush the working channels of scopes during the manual cleaning process. ATP testing detects microorganisms that remain in the scope’s channels and that must be removed before high-level disinfection can occur. The tests can be done in a matter of minutes and provide immediate results. Of course, every second counts in a busy GI center and adding any steps to the scope reprocessing process could impact overall efficiencies, so look for a testing product that’s easy to use, reliable and ready to read in minutes.

INFECTION CONTROL
6 Common Errors in Endoscope Care
WIDE SCOPE Implement proper reprocessing protocols and make sure staff follow the practices on a consistent basis.

The best way to prevent cross-contamination in your GI procedure rooms is to avoid making the following mistakes, says Libby Chinnes, RN, BSN, CIC, an infection prevention consultant based in Mount Pleasant, S.C., who’s seen them occur all too often in the facilities she visits.

1. Out-of-date IFUs. Following endoscopes’ instructions for use is easy to do when you purchase new instruments, but manufacturers regularly issue updates and changes to how the devices should be reprocessed. And all too often, these changes don’t get implemented. One of the most effective ways to ensure critical IFU updates don’t fall through the cracks is to designate a specific staff member to monitor updates and inform her colleagues about the changes. You can also partner with third-party consultants who will provide updates and educational programs on how to best implement the updates into your daily routines.

2. Inconsistent use of guidelines. It doesn’t matter which recommendations for proper endoscope handling and reprocessing you use — those issued by the Association for the Advancement of Medical Instrumentation, the Society of Gastroenterology Nurses and Associates or AORN, for example. What does matter is that you consistently apply the guidelines you choose to follow. Accreditation and Medicare surveyors don’t prefer one organization’s guidelines over another, but they will check to make sure you’re following one of the directives on a consistent basis.

3. Lack of training. How often do you train staff on cross-contamination prevention? Many facilities conduct refresher courses on an annual basis, during orientation for new hires and when new endoscopes or reprocessing equipment is purchased. That’s not often enough. Conduct staff-wide training — with physical demonstrations on how endoscopes should be cleaned and handled, and how automatic endoscope reprocessors work — more than once a year. The CDC recommends quarterly competency evaluations.

4. Inadequate pre-cleaning. Endoscope reprocessing begins at the patient’s bedside, where techs should wipe down the exterior of the insertion tube and flush internal channels as soon as procedures are concluded. This critical first step prevents biofilm from forming on the scope’s external and internal surfaces.

5. Inadequate manual cleaning. Even the best automatic endoscope reprocessors machines can’t disinfect endoscopes that haven’t been properly cleaned. Be sure diligent manual cleaning includes the flushing and brushing of all valves, channels, connectors and detachable parts.

6. Ignoring innovation. It doesn’t make sense to ignore the benefits offered by the technologies and tests that provide real-time evidence that scopes have been properly cleaned and disinfected. Take advantage of borescopes and real-time ATP testing to confirm scopes have been effectively reprocessed and are ready for repeated use.

— Jared Bilski

2. Consider disposables

Companies are developing disposable endoscopes with the aim of essentially eliminating cross-contamination risks. Previous generations of disposable scopes lacked the clinical performance of conventional models, but newer versions closely match the imaging capabilities and performance of standard scopes (check out one option in “Must-See Products at Digestive Disease Week” on page 22).

Single-use scopes are fantastic products, but in my opinion they’re not yet ready for routine use at this time, however, that will likely change in the near future. In the meantime, I see disposable scopes being ideally suited to supplement your standard scope inventory and readily available when patients have a known high level of bioburden or during off-hour procedures — to keep up with the Saturday colonoscopy trend, for example — when staffing the reprocessing room might be more expensive than paying between $300 and $400 for disposable scopes.

Reprocessing valve caps correctly — they must be removed, manually cleaned and undergo high-level disinfection — add to the responsibilities of your techs, who are under constant pressure to perform every step of the reprocessing process correctly every time. Disposable valves are available that eliminate the need to perform these steps — and perform them properly — during scope reprocessing. If you’re running a high-volume facility with scopes constantly cycling through the reprocessing area, disposable valves can hold a lot of value in the long-run.

3. Visually inspect

BRUSHING U\P

BRUSHING UP Manual cleaning is subject to human error, so put policies in place that check the work of your reprocessing techs.

Small-diameter borescopes serve as your eyes on the inside of scopes, a way to examine the channels for bioburden and internal defects. Reprocessing techs slide a durable endoscopic camera into an endoscope’s channels to examine the full length of each lumen. The high-resolution camera at the tip of the borescope captures clear, magnified images that are impossible to see with the naked eye. Like ATP testing, borescopes can be used to spot traces of tissue debris that could harbor microorganisms and jeopardize patient safety or unseen minor scratches and cracks that could negatively impact the function of the scope in the short term and, if not addressed, can ultimately lead to major malfunctions and expensive repair bills.

4. Maintain proper storage

INSIDER INFORMATI\ON
Weston Balch, CRCST, CIS, CHL
INSIDER INFORMATION Small-diameter borescopes let you examine the interior of scopes for residual bacteria and the first signs in interior damage.

After high-level disinfection, rinse the endoscope’s channels with water and perform a 70% alcohol flush to dry the channels. Remove suction valves and biopsy port covers — but keep them with the scope from which they were removed — before hanging the scopes in a storage cabinet to allow internal channels to air dry. Traces of water left in endoscope channels after high-level disinfection could lead to the growth of microorganisms during storage. Cabinets designed specifically for endoscope storage circulate HEPA-filtered air through the endoscope channels to assist in the complete drying of these channels. The length of time that endoscopes can be stored before having to be reprocessed again is up for debate. Clinical research is inconclusive in its advice, with studies showing 5 to 7 days as a limit while other papers indicate scopes can used safely within 21 days of being disinfected. It’s best to consider all available data and huddle with your infection preventionist and endoscopy clinical managers to develop a policy that makes sense for your facility’s case volume and endoscope use.

Reality checks

I’ve been working with endoscopes and in GI facilities for close to 4 decades. It seems that every few years a devastating outbreak related to improper endoscope reprocessing occurs or alarming research like the Johns Hopkins study is published to make us take a long, hard look at infection control programs in place across the country. Outbreaks and attention-grabbing research should serve as powerful reminders that proper endoscope care is an everyday responsibility that demands buy-in from everyone who handles scopes in procedure rooms and reprocessing areas. You shouldn’t ignore the importance of using any technology or tests that have the potential to assist your staff in protecting patients from infectious diseases. OSM

2. Consider disposables

Companies are developing disposable endoscopes with the aim of essentially eliminating cross-contamination risks. Previous generations of disposable scopes lacked the clinical performance of conventional models, but newer versions closely match the imaging capabilities and performance of standard scopes (check out one option in “Must-See Products at Digestive Disease Week” on page 22).

Single-use scopes are fantastic products, but in my opinion they’re not yet ready for routine use at this time, however, that will likely change in the near future. In the meantime, I see disposable scopes being ideally suited to supplement your standard scope inventory and readily available when patients have a known high level of bioburden or during off-hour procedures — to keep up with the Saturday colonoscopy trend, for example — when staffing the reprocessing room might be more expensive than paying between $300 and $400 for disposable scopes.

Reprocessing valve caps correctly — they must be removed, manually cleaned and undergo high-level disinfection — add to the responsibilities of your techs, who are under constant pressure to perform every step of the reprocessing process correctly every time. Disposable valves are available that eliminate the need to perform these steps — and perform them properly — during scope reprocessing. If you’re running a high-volume facility with scopes constantly cycling through the reprocessing area, disposable valves can hold a lot of value in the long-run.

3. Visually inspect
BRUSHING UP Manual cleaning is subject to human error, so put policies in place that check the work of your reprocessing techs.

Small-diameter borescopes serve as your eyes on the inside of scopes, a way to examine the channels for bioburden and internal defects. Reprocessing techs slide a durable endoscopic camera into an endoscope’s channels to examine the full length of each lumen. The high-resolution camera at the tip of the borescope captures clear, magnified images that are impossible to see with the naked eye. Like ATP testing, borescopes can be used to spot traces of tissue debris that could harbor microorganisms and jeopardize patient safety or unseen minor scratches and cracks that could negatively impact the function of the scope in the short term and, if not addressed, can ultimately lead to major malfunctions and expensive repair bills.

4. Maintain proper storage
INSIDER INFORMATION Small-diameter borescopes let you examine the interior of scopes for residual bacteria and the first signs in interior damage.

After high-level disinfection, rinse the endoscope’s channels with water and perform a 70% alcohol flush to dry the channels. Remove suction valves and biopsy port covers — but keep them with the scope from which they were removed — before hanging the scopes in a storage cabinet to allow internal channels to air dry. Traces of water left in endoscope channels after high-level disinfection could lead to the growth of microorganisms during storage. Cabinets designed specifically for endoscope storage circulate HEPA-filtered air through the endoscope channels to assist in the complete drying of these channels. The length of time that endoscopes can be stored before having to be reprocessed again is up for debate. Clinical research is inconclusive in its advice, with studies showing 5 to 7 days as a limit while other papers indicate scopes can used safely within 21 days of being disinfected. It’s best to consider all available data and huddle with your infection preventionist and endoscopy clinical managers to develop a policy that makes sense for your facility’s case volume and endoscope use.

Reality checks

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