Flexible Endoscope Storage Solutions

It’s time to upgrade to cabinets that actively dry your scopes.

Infection prevention and sterile processing pros who visit GI centers continue to see the use of inadequate endoscope storage methods that can foster contamination inside the long stretches of tubing as the reprocessed devices hang between cases.

“I’ve been to endoscopy centers that have homemade cabinets, or ones with a hole in the side that would theoretically allow for ventilation with a little aftermarket fan added,” says Frank Edward Myers, MA, CIC, FAPIC, director of infection prevention and clinical epidemiology at University of California San Diego Health. “That’s obviously not the standard and not recommended by any group anymore.”

Sterile processing educator Casey Czarnowski says these experiences show just how far the industry’s standard of care is misaligned with current recommendations and guidance from regulators and associations. “It’s not unheard of for centers to use cabinets not specifically designed to store endoscopes,” he says. “Inappropriate cabinets, purchased at any big-box store, are definitely still out there in use.”

Where to start?

The updated standard from the Association for the Advancement of Medical Instrumentation (AAMI) released in 2021 includes revised storage recommendations — and starts with the fundamental premise that cabinets used to store flexible endoscopes should be expressly designed for that purpose.

Guidance from AAMI, the Society of Gastroenterology Nurses and Associates (SGNA) and others says that facilities should have protocols detailing how to clean the cabinets themselves based on manufacturers’ instructions. “Obviously, a household-type cabinet doesn’t come with cleaning instructions, so that should be your first clue and warning sign that it’s not acceptable,” says Mr. Czarnowski. “A cabinet with no instructions for use from the company that made it means your sterile processing staff won’t know how to clean it.”

The 2021 AAMI standard recommends two types of cabinets for storing flexible endoscopes after they have undergone high-level disinfection or liquid chemical sterilization. Each circulates HEPA-filtered or instrument air through the cabinet at continuous positive pressure. One type is referred to as “conventional cabinets,” because they don’t include a method of circulating forced air through the long, narrow channels of the scopes. “Drying cabinets,” meanwhile, have that feature, which attaches a forced-air delivery system onto each endoscopic channel.

• Drying cabinets. The latest standard notes that multiple studies have shown these cabinets can reduce moisture within the channels, which in turn reduces the potential for microbial contamination. Mr. Myers considers advances in drying cabinets — how the channels and lumens of endoscopes are connected to cabinets’ ventilation systems — to be the biggest breakthrough in the last five to 10 years in reducing infections surrounding GI procedures. Some models have monitors that measure the humidity levels in the cabinets, as well.

“We know from a number of published articles that the drying cycles of automated endoscope reprocessors in use do not get the insides of those lumens or channels dry,” says Mr. Myers. “As a result, water remains in them and any time you have residual water, there is the potential for life.”

EVEN FLOW Current guidance recommends scopes be placed in cabinets that at least have air circulating through them during the entire storage cycle.

Drying cabinets that directly attach to the scopes are more the standard of care in Europe than in America but are gaining steam here. Mr. Myers says he expects consensus in the future that they’re better than conventional cabinets from additional studies concluding that forced air through the channels nearly eliminates the potential for bacterial growth because the channels are dry. Change could also be spurred by recent warning letters from the U.S. Food & Drug Administration to endoscope manufacturers urging a stringent adherence to sound reprocessing techniques.

• Conventional cabinets. These systems, though they don’t attach to the scope channels, still meet the 2021 AAMI standard and are far superior to storing scopes horizontally, hanging them on the wall or using a non-medical cabinet with no circulation system.

“The minimum recommended practice, while still not mandatory, is cabinets that have HEPA filtration and constantly circulate air in the cabinet,” says Mr. Myers. “They do an excellent job of assuring that the outsides of the endoscopes are dry, make for an overall drier environment in the cabinet and could even have a drying effect on those internal lumens in the infrequent scenarios that see scopes being stored for long periods of time before they are used again.”

The latest AAMI standard says to dry these scopes before they’re stored, which Mr. Czarnowski says is a challenging and time-consuming process. Flexible scopes are delicate and must be handled accordingly, and it’s difficult to access the long, narrow channels.

“It can take hours for a tech using an air hose by hand to get a scope thoroughly dry,” he says. “This clearly isn’t ideal at a high-volume scope center.”

• Worth the money. Air-circulating cabinets can range from $4,000 to $8,000. Mr. Myers said the cabinets are worthy investments against potentially serious infections that can be disastrous for patients and for a scope center’s reputation.

“It’s not something you ever want,” he says. “These circulation systems, particularly drying cabinets, are a very strong insurance policy against having a scope being linked to potentially fatal outbreaks.”

It’s been about a decade since Mr. Myers has seen scopes hanging on a wall. Most are now in cabinets of some sort, which is an improvement, even if the motivation is simply to protect the devices because they’re expensive and not an infection control measure. Up until about five years ago, he’d seen outpatient facilities place cups under the scopes to catch the water that dripped from the ends of the channels. He also saw scopes stored horizontally in the cases sent back to the manufacturer, but that’s now a rarity. Some infection prevention pros, he says, still are of the mistaken belief that you can’t fully dry the channels, even with the advent of drying cabinets. “What I’ve seen in the community has mostly reflected the concept that there needs to be a protected environment around the scope to avoid accidental contamination and accidental damage,” says Mr. Myers. “Many organizations, especially larger ones, are being more aggressive in their use of drying cabinets because they’re aware of the literature that links moisture in scopes to infection outbreaks.”

The latest AAMI standard also recommends that cabinets be located in secure environments such as a clean workroom. The old practice of hanging them in procedure rooms isn’t good from an infection standpoint, nor is it a good experience for the patient if staff comes in to get a scope for a different room during their procedure.

Final thoughts

Whichever circulating cabinet you choose, Mr. Czarnowski says it’s important to assign one person to change HEPA filters and to craft a procedure for how often they will be changed. Change times should be documented in case a surveyor asks about your process.

The AAMI standard also recommends that the cabinet doors be kept closed and located three feet from any sinks. They should be cleaned at least once a week and whenever they are visibly dirty. “Organizations are calling for drying cabinets because they realize that technicians almost literally can’t do enough to get the insides of these scopes dry,” he says. “It’s almost impossible to do so in a reasonable timeframe in a way that could really diminish the chance of microorganisms growing inside the scope.” OSM