The Essential Elements of Endoscope Reprocessing

The reprocessing of flexible endoscopes involves dozens of steps that must be performed correctly every time by staff members who follow an airtight scope handling process that protects patients from cross-contamination risks. Let’s review the basic steps every endoscopy center should have in place.

• Point-of-use cleaning. After each procedure, a nurse or tech should perform a bedside flush of the scope’s channels, and wipe down the exterior and components. “They need to get rid of as much gross contamination on the scopes as they can,” says Michelle Alfa, MSc, PhD, FCCM, a former professor and researcher at the University of Manitoba who has started her own firm, AlfaMed Consulting in Winnipeg. Because this step is often missed or forgotten in busy facilities, Dr. Alfa recommends requiring staff to document that it’s completed after each procedure. “Bedside cleaning is the best opportunity to remove the vast majority of patient secretions from the scope,” she says.

• Safe transport. After bedside cleaning, transport scopes to the reprocessing room as soon as possible to prevent residual materials from hardening and becoming more difficult and time-consuming for reprocessing staff to remove. “If the transit time is prolonged, residual secretions have a longer timeframe with which to adhere to the scope’s surfaces, and they become harder to remove,” says Dr. Alfa.

Keep the scope moist inside the transport container using appropriate foams and sprays. Best practice for transport to the reprocessing room is to place the scope inside a rigid container with a properly labeled lid that protects it from any damage.

The guidelines recommend starting the reprocessing of scopes within a maximum of an hour after procedures are performed. “When techs get pressured by a backlog, they know they need to speed up,” says Dr. Alfa. “As a result, instead of doing all of the manual cleaning steps meticulously, they sometimes cut corners.” If backlogs persist, you likely need more techs on the line or more scopes in your fleet.

Bedside cleaning is the best opportunity to remove the vast majority of patient secretions from the scope.
— Michelle Alfa, MSc, PhD, FCCM

• Manual cleaning. Perform a leak test to ensure the scope isn’t damaged and wipe down its exterior with an appropriate detergent, says Dr. Alfa. During this manual cleaning step, the scope should remain immersed under the sink’s fluid level to avoid generating aerosols that can splash up and expose techs to patient-derived organisms. The tech should thoroughly clean the scope with the detergent solution, flushing all the channels several times based on the manufacturer’s instructions for use, and brush the inside of channels to provide friction. “Without friction, you don’t get good cleaning,” says Dr. Alfa. The cleaning should be followed by full rinsing with tap water to remove loosened debris and the detergent.

Manual cleaning is the aspect of endoscope reprocessing where variability in technique, training, effort level and time constraints converge to create a wealth of potential failure points. “Many sites don’t monitor how well manual cleaning is done,” says Dr. Alfa, noting that it’s important to test the cleanliness of scopes before they go into an automated endoscope reprocessor (AER) for high-level disinfection. “If you don’t perform the manual cleaning properly, high-level disinfection isn’t going to be effective,” she says.

• Spot checks. Rapid sampling tests for the presence of adenosine triphosphate protein (ATP) and hemoglobin can detect residual materials after manual cleaning. “If they don’t pass, they should be recleaned and retested before they’re allowed to be high-level disinfected,” says Dr. Alfa. “By using these rapid tests in real time, techs can determine if they actually cleaned the scope properly.”

Dr. Alfa suggests that if you can’t test each scope, you should absolutely test duodenoscopes, which have been at the center of outbreaks of multidrug resistant organisms. The devices are challenging to clean because of the elevator channel’s intricate design, which is difficult to access with brushes.

Venkataraman R. Muthusamy, MD, MAS, medical director of endoscopy at UCLA Health, agrees that duodenoscopes require extra attention. “They’re the one type of scope that can pose a challenge, even when they’re cleaned properly,” he says. “When the FDA asked the manufacturers to submit specimens from sites that they felt did it right, the rate of pathogenic bacteria was around 5%, which is more than tenfold what they had expected.” 

Dr. Muthusamy notes that researchers are investigating the effectiveness of alternative cleaning techniques, such as low-temperature sterilization, and scope manufacturers have designed duodenoscopes whose elevator (or the distal cap that protects it) are disposable and, more recently, fully disposable duodenoscopes. “There’s a growing understanding that there is an issue and there’s a lot of innovation,” he says.

• Proper storage. When scopes are removed from AERs, they should be thoroughly rinsed with bacteria-free water, and then dried before being placed in storage. The key to storing high-level disinfected scopes is to keep them dry. “Microbes can only replicate and start forming biofilm in the presence of moisture,” says Dr. Alfa. The problem is that it can take a tech 10 minutes with a compressed air gun to dry one channel of one scope. Dr. Alfa says cabinets that actively dry the channels of scopes will save time and labor by automating the drying process and ensuring scopes remain dry and safe.

It’s incumbent upon facility leaders to monitor their staff’s compliance with proper endoscope care. “Reprocessing a scope is not a race,” says Dr. Alfa. “You need to have enough staff and give them enough time and the appropriate tools to do it properly.” OSM

Note: This three-part article series is supported by ASP.