BY DESIGN Difficult-to-clean duodenoscopes have been linked to several deadly outbreaks of antibiotic-resistant bacteria.

The ceaseless wave of endoscope reprocessing mishaps making headlines across the country has hammered home the point that you can't reprocess a dirty scope. Proper manual cleaning is a challenge under normal circumstances, but nearly impossible when you pressure reprocessing techs to hurry up because a patient is waiting for his procedure to begin, or if you expect techs to get scopes cleaned, disinfected and back in a procedure room in less than an hour.

Scope techs essentially work blindfolded — Here's a brush, now remove the bioburden that you can't see inside the scope. They're told to brush a scope's internal channels until the brush they're using appears clean. Techs must rotate brushes 360 degrees as they clean scopes' internal channels, but I haven't seen that attention to detail in many of the GI clinics I've visited. When I've asked reprocessing techs how many times they brush a scope's channels during manual cleaning, some tell me they run the brush through just once. Why do we allow that inexcusable shortcut? Assuming cleaning practices are eh, good enough is never good enough when it comes to endoscope reprocessing.

Are aging technicians who need glasses to read endoscope cleaning directions really able to notice every little speck on a brush's bristles? Relying on the visual inspection of a channel brush to confirm the cleanliness of a scope increases the potential for human error. That's why your reprocessing area should be outfitted with adequate lighting and magnifying glasses staff can use to confirm brushes are in fact as clean as they appear at first glance. It should also have a clear flow from dirty to clean and adequate workspace for techs to clean scopes properly.

Better yet, you can spot-check the cleanliness of the endoscopes before high-level disinfection takes place. Here are 3 ways to do so:

• Adenosine triphosphate (ATP) testing detects bacteria levels in the scope's channels. ATP is an enzyme found in all living cells and is present on any contaminated surface. An ATP monitoring system can detect the amount of organic matter that remains after manually cleaning an endoscope.
• Routine surveillance culturing.
• Inserting a borescope into an endoscope's channels provides direct views of internal lumens and groves, where biofilm hides and brushes might not be able to reach. Adding borescopes to your reprocessing regimen is arguably the best way to ensure endoscopes are cleaned properly.

BASIC TRAINING Proper manual cleaning is arguably the most important step of endoscope reprocessing.

In the news
Reports of deadly antibiotic-resistant bacteria outbreaks have splashed across national headlines in recent years. In early 2015, 2 patients died after being infected with carbapenem-resistant Enterobacteriaceae (CRE) during endoscopic retrograde cholangiopancreatography (ERCP) performed at UCLA Medical Center in Los Angeles. Later that year, Virginia Mason Medical Center in Seattle, Wash., reported the deaths of 11 patients who were also infected with CRE during ERCP. The outbreaks at both facilities were ultimately linked to dirty duodenoscopes used during the procedures.

The dangers of cross-contamination aren't limited to tough-to-clean duodenoscopes. In January 2016, Baystate Noble Hospital in Westfield, Mass., notified 293 patients that they might have been exposed to bloodborne pathogens after it was discovered that colonoscopes used at the facility during a 10-month period weren't properly disinfected. This past January, an untrained nurse at Crozer-Chester Medical Center in suburban Philadelphia used an improperly disinfected endoscope on an elderly patient. State inspectors found that the nurse first attempted to perform the endoscopy with a properly cleaned instrument but had difficulty and then proceeded with a scope that had been used on a prior patient, but had only been pre-cleaned and not completely disinfected.

CDC investigators and the maker of the duodenoscopes linked to the outbreak at UCLA determined staff members followed the manufacturers' reprocessing directives to the letter. That biofilm wasn't able to be removed from the scopes, even after they were cleaned properly, points to a design that's challenging to clean. Specifically, it's difficult to completely remove bacteria from a duodenoscope's elevator mechanism during manual cleaning, before proper high-level disinfection or sterilization can take place.

Following the outbreaks, duodenoscope manufacturers have made design changes to reduce risk of contamination in that problematic area. They've also updated disinfection instructions to require the use of a special disposable brush designed specifically to clean the elevator channel. But the onus ultimately rests with reprocessing techs, who must take time to meticulously brush the elevator mechanism, a process that includes raising and lowering the mechanism to allow for brushing of both sides.

After its outbreak, Virginia Mason took its reprocessing efforts a step farther. The hospital now places every reprocessed duodenoscope in quarantine for 48 hours; only after culturing indicates no harmful bacteria remain in the instruments can quarantined scopes be used again.

The scope redesigns and new reprocessing directives have presumably mitigated much of the cleaning problems that led to the outbreaks. Infection preventionists and reprocessing techs have a better understanding of the reprocessing process. On the other hand, the complex design of duodenoscopes means some parts of the scope are extremely difficult to assess and effective cleaning of all areas may not be possible. In addition, national standards on scope reprocessing vary on their guidance on how to deal with these challenges. Problems associated with duodenoscopes aren't caused by the people doing the cleaning; they're the result of the complex design of the scopes, and that hasn't changed.

Why not sterilize?
Part of the positive that has come out of the CRE outbreaks is that facility leaders are much more involved in efforts to ensure flexible endoscopes, and especially high-risk duodenoscopes, are properly cleaned. There's more of a willingness to adopt technologies for validating scope cleaning that have not been used as aggressively as they could have been in the past.

Some experts believe it's time to move beyond high-level disinfection by sterilizing flexible endoscopes. I'm not sure that would be an effective strategy. Whichever sterilizing technology is used — chemical sterilants, ethylene oxide, hydrogen peroxide or gas plasma — has to come in contact with the harmful organisms that reside inside scopes. If biofilm isn't effectively removed during scope cleaning, as is often the case, sterilization's effectiveness can be limited.

Sterilization does provide a higher kill rate than high-level disinfection, but improving cleaning practices is where facilities need to focus their infection prevention efforts. I contribute to the endoscopy standards for the Association for the Advancement of Medical Instrumentation. Many people within the group believe sterilization has to play a larger role in endoscope reprocessing than it does now, but none that I have spoken to believe it would solve the problem of trying to reprocess dirty scopes. OSM