The endoscopes that doctors at Henry Ford Hospital in Detroit used toperform nasal pharyngoscopy tests on 268 patients may have been contaminatedwith hepatitis B or C, according to a recent newspaper report. The culpritin this case of cross-contamination? A foam-padded suitcase where theendoscopes were stored had become a hepatitis breeding ground.What about your facility? Are you doing all you can to preventcross-contamination? We ask infection control experts how to prevent theproblem from occurring with these three hard-to-clean instruments:

• flexible endoscopes
• biopsy forceps
• laryngoscopes blades and handles

Flexible endoscopes
Flexible endoscopes are a notorious source of cross-contamination, theirlong, narrow channels a challenge to reprocess. If not properly cleaned,flexible endoscopes can spread any number of infectious diseases, includingbloodborne viruses such as HIV and hepatitis B and C, as well as numerousother pathogens ranging from Helicobacter pylori from gastrointestinalscopes to Mycobacterium tuberculosis from ENT scopes.

We asked Steve Goldstine, PhD, a senior scientist who manages microbiologyat Olympus America, Inc., to share some common mistakes to avoid whenreprocessing endoscopes.

• Failing to reprocess all internal channels, including the specializedones, every time you reprocess the scope. Sometimes, channels that were notused during the procedure will not be reprocessed.
• Reprocessing sharp instruments, such as biopsy forceps, along withflexible endoscope. This can damage the device, allowing fluids to leak intothe channel, corrode the internal parts of the endoscope, and harborbacteria.
• Reusing detergent solutions and rinse water during manual reprocessing.The detergent solutions and rinse water must be changed after every scope.
• For automated disinfectors, not hooking up the endoscope to the propercorresponding connector.
• Using chemicals and processes that are incompatible with your endoscopes,according to your manufacturer's manual. This may cause the scopes to bedamaged or improperly cleaned.

5 Steps to Cleaning Your Flexible Scopes Correctly 1. Precleaning. Preclean immediately after endoscope use to prevent bloodand tissue becoming caked on. Be sure to use detergent (not disinfectant)for removal of gross debris from exterior surfaces and internal channels.According to Dr. Goldstine, disinfectant actually causes the patientmaterial to coagulate, making it more difficult to remove. 2. Leakage testing. Test the scope every time it is reprocessed. 3. Manual cleaning and rinsing. Ensure you have cleaned all channels byusing channel adapters, and always manually clean scopes before using anautomated cleaning system 4. High-level disinfection and rinsing. Follow disinfectant manufacturer?slabel instructions for soak time and temperature. Also thoroughly rinse thescope to remove traces of disinfectant. Any agent that is left in the scopecould potentially damage your patients as well as the scope. Dr. Goldstinealso recommends that you alcohol flush and air dry internal channels afterdisinfection. 5. Storage. Endoscopes should be stored hanging vertically (not coiled) in adry environment, and removable parts (for example valves) should not bereattached during storage. Parts such as valves can be cleaned along withthe endoscopes and then autoclaved.

Biopsy forceps
Due to the tight coil-like windings and joints of biopsy forceps, microbescan become lodged in the crevasses, where disinfectant cannot penetrate,leading to possible cross-contamination. Like flexible endoscopes, biopsyforceps come in contact with numerous possible contaminants both bacterialand viral.

"Immediately after use, the forceps must be cleaned to remove mucus, tissueand blood from the instrument," says Dan Alt, a senior project engineer withECRI, a non-profit healthcare agency in Plymouth Meeting, Pa. Soil that isleft to dry on used forceps cause the device to deteriorate and make it evenmore difficult to remove this potentially infectious material. If you cannotreprocess the device right away, most manufacturers recommend placing theinstrument in a container of warm detergent solution until you can clean it.You may also want to try using an ultrasonic cleaner to remove any remainingdebris.

Laryngoscopes blades and handles
According to Kay Ball, an infection control consultant with K D MedicalInc, Lewis Center, Ohio, laryngoscope blades and handles are anotherpotential source of cross contamination. These devices are used like aretractor to open and illuminate the throat, allowing easy access for thebronchoscope. According to Ms. Ball, some facilities do not take the time toproperly disinfect laryngoscope handles and blades. Studies have shown thatnosocomial infections, like M. tuberculosis and pneumonia, can betransmitted as a result of inadequate cleaning, improper use of disinfectionagent, or failure to follow recommended cleaning and disinfectionprocedures.Here are some recommendations from the American Society of Anesthesiologistsfor properly sterilizing your laryngoscope blades and handles:

• Begin cleaning the instruments with a low-sudsing enzymatic detergent assoon as possible after use.
• Brushes used for cleaning should be disposable or should be cleaned andsterilized or undergo high-level disinfection at least daily.
• When using liquid disinfectants for high-level disinfection, all internaland external surfaces must be in contact with an EPA-registeredsterilant/disinfectant for at least 20 minutes. And then rinse the equipmentthoroughly (including channels) with sterile water followed by a 70-percentalcohol rinse.
• Nonimmersible parts should be physically cleaned with water and detergent,then wiped with 70-percent alcohol.

Consistently follow procedures
When it comes to properly reprocessing devices, Dan Alt advises to alwaysfollow the manufacturer's instructions, keep in mind the risk level of thedevice and look at the instrument's geometry. If you are dealing with anintricately constructed device, you are going to have to give careful timeand patience to see that it is thoroughly cleaned.

"In most cases, cross-contamination problems arise not because properprocedures were not in place, but because these procedures were not followedconsistently," says Mr. Alt. He recommends adopting a policy of bothadequate training as well as routine monitoring. He also recommendsconsulting your manufacturer's instructions if you have any questions aboutreprocessing instruments and devices.

Contact Kristin McKee at 610.240.4918, ext. 15 or [email protected].