By Don Sadler
Flexible endoscopes are some of the most critical pieces of equipment used in operating rooms today. This makes proper endoscope cleaning and processing one of the most important tasks that perioperative nurses must perform.
Failure to properly clean and process endoscopes can lead to many different problems. These range from increased risk of infections and exposure of patients to hazardous and toxic chemicals to surgical delays that cost hospitals time and money.
High Infection Risk
According to Mary Ann Drosnock, MS, FAPIC, CIC, CFER, RM (NRCM), senior manager of clinical education with Healthmark Industries, infections are at the top of the list of potential negative outcomes from failing to properly process endoscopes.
“If an endoscope is not thoroughly manually cleaned and verified by inspection and cleaning monitors, organisms can survive the disinfection or sterilization process,” says Drosnock. “These organisms could be infectious to subsequent patients.”
Natalie Lind, CRCST, CHL, FCS, education director with the International Association of Healthcare Central Service Material Management (IAHCSMM), says that the main priority when it comes to endoscope processing is making sure scopes are safe for use on the next patient.
“We must produce a device that’s safe and poses no risk of infection to the next patient,” she says. “We also need to be concerned about damaging the endoscope.”
Not all damage renders an endoscope unusable, Lind adds. “For example, cloudy lenses diminish the ability to visualize tissue, which could cause the physician to miss something.”
Improper handling of endoscopes after processing can also lead to problems.
“Endoscopes must be handled in a manner that prevents contamination,” says Lind. “They must be stored dry and delivered safely to the patient bedside.”
Increased Attention and Focus
The good news when it comes to proper endoscope cleaning and processing is that the subject has gotten a lot of interdisciplinary attention over the past few years, says Erin Kyle, DNP, RN, CNOR, NEA-BC, perioperative practice specialist with the Association of periOperative Registered Nurses (AORN).
“Because of this, a greater degree of interprofessional collaborative focus has now been placed on the whole process and how professionals can work together to improve it,” says Kyle.
One result of this increased focus on proper endoscope cleaning and processing is that health care professionals are leveraging technology to streamline and standardize endoscope processing steps, she adds.
Examples of this technology are automated endoscope reprocessors (AER), visual inspection with borescopes and endoscope drying cabinets.
“These cabinets include continuous forced filtered air through the endoscope channels,” says Kyle.
According to Drosnock, another result is the addition of a new inspection step after manual cleaning and prior to disinfection or sterilization. She explains that this new inspection step is a three-fold process encompassing a visual inspection with lighted magnification, enhanced inspection into internal channels using a borescope and a cleaning verification test.
“This is an exciting trend in endoscope processing,” Drosnock says. “A true state of the endoscope can now be assessed by showing whether there is residual debris left on the scope that could interfere with the disinfection or sterilization process,” says Drosnock. “It can also show whether there is damage to the endoscope that would render the item unsafe to use.”
J. Scot Mackeil, CBET, senior anesthesia BMET, believes that adding a “pass through” reprocessing facility to provide separation between the dirty and clean sides of the cleaning facility is “one of the most significant upgrades to the practice.”
“I also give a lot of credit to ECRI and AAMI for safety alerts, standards, education and outreach, as well as raising awareness and providing practical, effective and actionable scope safety practices, procedures and standards,” says Mackeil.
“ECRI’s annual top 10 safety lists have focused on scope safety year after year,” Mackeil adds “AAMI standards on scope processing are key tools as well.”
National Best Practice Standard
The national standard for best practices in endoscope processing is ANSI/AAMI ST91, “Flexible and Semi Rigid Endoscope Processing in Healthcare Facilities.” Drosnock says this document was originally published in 2015 and is currently in the revision process.
“The document provides guidelines for processing all types of flexible endoscopes and for all stages of reprocessing, including HLD and sterilization steps,” says Drosnock. “Information can be found for any type of flexible scope, including bronchoscopes, ureteroscopes, gastroscopes and colonoscopes.”
ST91is applicable to all health care settings, not just hospital-based facilities.
“This means all health care facilities that process endoscopes are held to the same standard of care,” says Drosnock.
Meanwhile, the “AORN Guideline for Processing Flexible Endoscopes” was last updated for the 2017 edition of the “AORN Guidelines for Perioperative Practice.”
“It’s great to see that many of the recommendations in these guidelines have become trends in current practice,” says Kyle.
She notes a few of these recommendations in particular. For example, Recommendation VIII.c. indicates a preference for automated processing over manual methods. And Recommendation VII.c.1 specifies that internal channels of flexible endoscopes may be inspected using an endoscopic camera or borescope.
“Visual inspection is a fundamental step in ensuring complete cleaning of all reusable medical devices,” says Kyle. “The use of borescopes is essential to achieve this crucial step when inspecting the most difficult to clean portions of endoscopes like the lumens, channels and elevator mechanisms.”
In addition, Recommendation IX.b.1. states that flexible endoscopes should be stored in a drying cabinet.
“This facilitates complete drying, decreases the potential for contamination, and provides protection from environmental contaminants,” says Kyle.
Drosnock believes that these and other best practices for endoscope cleaning and processing should be engineered into the process as part of a quality management system.
“They provide immediate feedback on the inspection and cleaning verification process and help prevent poor outcomes such as biofilm development, which can happen during drying prior to storage,” she says.
Collaboration and Communication
Kyle stresses the importance of interdisciplinary collaboration and strong team communication when it comes to successful endoscope cleaning and processing. She mentions physicians, point-of-use personnel and decontamination personnel specifically.
“Physicians should be knowledgeable about endoscope processing and supportive of the team doing the processing so they can perform all the steps correctly and never feel rushed,” she says.
Expedient and correct point-of-use treatment, commonly known as “precleaning,” is also essential to the process, Kyle adds.
“When point-of-use treatment occurs with the correct solutions as soon as the scope is removed from the patient and is no longer needed in the procedure, complete decontamination is easier and takes less time,” she says.
Finally, it’s imperative that decontamination personnel know whether point-of-use treatment occurred once they receive the endoscope. “This makes a difference in how they clean the endoscope,” she says.
The endoscope manufacturer’s instructions for use (IFU) also must be carefully followed. Lind says there is often tremendous pressure to quickly process endoscopes so they can be used again.
“This pressure can tempt staff to shorten or skip steps in the IFU to meet time demands,” says Lind. “However, the IFU should always be followed exactly as written.”
A Culture of Safety
Mackeil believes that proper endoscope cleaning and processing comes down to health care organizations fostering a culture of safety and performance excellence at all levels.
“True endoscope safety requires adoption of best practices, vigilance and proven processing technologies,” he says. “It also requires a pervasive infusion of training, excellence and safety mindedness on the part of all health care providers along the continuum of patient care.”