New Standards in Endoscope Reprocessing

Best practices in the high-level disinfection of flexible endoscopes must be prioritized after every one of the estimated 15 million colonoscopies performed each year in the U.S., says James Collins, BS, RN, CNOR, endoscopy accreditation nurse for the Digestive Disease & Surgical Institute at the Cleveland Clinic. He’s one of seven co-authors of the latest multisociety guideline on reprocessing flexible GI endoscope and accessories, which was published in January 2021.

Last March, the Association for the Advancement of Medical Instrumentation (AAMI) released the updated ANSI/AAMI ST91:2021/ standard for the reprocessing of flexible and semi-rigid endoscopes. Some of the key revisions and additions involve factors related to decontamination sinks; training competency and certification; HVAC and water quality monitoring; leak testing; broadened cleaning and inspection steps; heightened focused on endoscope drying; and revised storage requirements. “Drying and storage has become one of the elements being looked at more closely, due to the fact that wet endoscopes are a hazard for bacterial growth,” says Mr. Collins. “We know more about biofilms and how they work, and the effects they have on wet scopes that aren’t dried properly.”

Randall Rentschler, RN, BA, CNOR, CSSM, TNS, perioperative service director at Artesia (N.M.) General Hospital, says the latest revisions will require “sweeping changes” to many GI suites and their budgets. His hospital included. Mr. Rentschler is already working through implementing the changes, including requirements related to installing forced-air drying cabinets, which he notes is an expensive upgrade. “The expectation is to have drying cabinets with integrated adapters that connect to flexible scopes and force HEPA-filtered air through their channels,” he explains. “Also, the scope cabinet can no longer be kept in rooms where procedures are performed. There needs to be a separated area for scope storage, and facilities must maintain separation between clean and dirty workflows.”

Mr. Rentschler points to other key updates to AAMI’s standard: automated endoscope reprocessors (AERs) must be six feet from the manual cleaning sink; a three-tank sink for separate leak testing, manual cleaning and rinsing of scopes prior to placement in AERs; use of borescopes to visually inspect a scope’s lumens for damage or dampness; and confirming a scope is dry before hanging it in a storage cabinet.

Frank Edward Myers III, MA, CIC, FAPIC, director of infection prevention and clinical epidemiology at UC San Diego Health, supports the updated standard. “It’s a good upgrade from where we were,” he says. “I’m excited about beginning to assess drying cabinets. We know there are many AERs on the market that haven’t been adequately drying internal channels of scopes.”

I’ve always believed reprocessing techs are the heart of the GI unit.
— James Collins, BS, RN, CNOR

Mr. Meyers welcomes the push for three-bay sinks. “There are many facilities still trying to reprocess scopes in a one-bay sink, which is an invitation for cross contamination,” he says. He’s also excited to continue advancing the use of borescopes as part of the cleaning process. “We ask our techs to clean the channels of scopes,” he says, “but we’re asking them to clean without being able to see inside.”

Mr. Meyers believes GI professionals who advocate for the safety of patients will back the changes. “That is not to say there aren’t challenges involved in making them happen,” he says. “Many accrediting bodies have adopted these practice changes and that posed a challenge for some facilities because of the capital expenses involved.” While there is always a little resistance when finances are involved, he says, “Overall, everyone understands the importance of these process improvements.”

While strict adherence to standard but constantly evolving evidence-based steps in a flexible endoscope reprocessing program is essential to reducing cross-contamination risks, Mr. Collins believes any infection prevention program is only as effective as the individuals who back, teach and implement it.

“First and foremost, we have to start with education and training,” he says. “We need to ensure that our reprocessing staffs are keenly aware of the correct instructions for use to properly process the endoscopes they have in their inventory, and that they have support of facility leadership.”

In his training, Mr. Collins stresses the importance of each step in the cleaning and high-level disinfecting process, and that every step deserves equal attention. “If there is a failure anywhere in those steps, then chances are there won’t be a good outcome,” he says. “There are no shortcuts in endoscope reprocessing and sometimes steps need to be repeated.” 

Mr. Collins acknowledges that being part of an endoscope reprocessing team is a stressful job, and not always a rewarding one. “That’s why we need to build these individuals up and ensure they feel like they’re a valued team member,” he says. “I’ve always believed reprocessing techs are the heart of the GI unit because procedures can’t be performed without a clean scope.” OSM