The responsibility for effective endoscope care is ultimately in your hands. You employ staff members to handle and reprocess your scopes, of course, but the value of supervisors playing an active role in their care and handling cannot be overstated.

Make occasional rounds to observe and keep track of your staff's handling of your flexible scopes and your sterile processing department's cleaning and disinfecting of them. A weekly walkthrough can go a long way. During your visits, spend time talking with your nurses, techs and reprocessors. Ask them what can be done to improve the process and reduce the need for repairs and whether a remedial or refresher training session is in order.

An administrator who stays current on the manufacturers' directions and infection control guidelines for the high-value devices on which her business is built — who knows, for instance, how they're put together, why they're hung for storage and not tightly coiled for transportation, whether the disinfecting logs are signed off — will be better able to identify any problems before they become major issues. And an administrator who is able to demonstrate proper care will find it easier to correct staff members' errors with a teachable moment if they discover any lapses in technique.

Your flexible endoscope is a $20,000 to $40,000 piece of equipment. Some may even eclipse the $70,000 mark. One damaged scope sent out for an overhaul can cost you $12,000. Don't you think it's worth it to invest a couple thousand dollars into training and education for the nurses and techs who handle your scopes on a daily basis? Professional societies with a focus on gastrointestinal procedures and personnel, and even some states' departments of health, offer staff training sessions on scope reprocessing.

Scope manufacturers are also an excellent resource. Their representatives often have ready-made, interactive in-services on proper use, handling, reprocessing and repair reduction techniques and are available to present them at your facility for no cost. Sometimes participants can even earn continuing education contact hours. At a total ballpark estimate of about $600 for an hour or so of overtime for 10 to 12 staff members, that's a minimal budget expense for the big payoff of extending a scope's usable lifespan another year or two.

Consider restricting the staff who handle your scopes through specialized training or competency certification. To this end, scheduling separate training sessions for physicians and staff may prove helpful. While physicians learn about the application capabilities of the scope, the nurses, scrub techs and reprocessors learn about its technical aspects. However you arrange training, make sure it's a recurring effort and not a once-and-done event, particularly when new staff or new equipment are brought on board. Since most facilities see generations of staff and equipment overlap, make it a point to upgrade your training when you upgrade your center.

As a technology, endoscopes haven't radically changed over time. While high-definition imaging and contrast lighting have increased the quality and ability of their visual output, they remain flexible black tubes with cameras on one end and controls at the other. Some models have grown longer, though. Since a scope should be stored vertically, with the insertion tube hanging freely, not resting on the floor or doubled back, be sure your storage cabinet is properly sized to accommodate all of your scopes with enough vertical clearance.

An observant manager can identify potential scope reprocessing problems just by looking at the cabinet. When you open your scope cabinet, does it smell clean, or do you detect the odor of bioburden? A little debris goes a long way. Some people put absorbent pads on the cabinet floor to collect any matter that drips out of a hanging scope. Brown or red stains on the pads indicate that the bioburden wasn't entirely removed. Green means that residual glutaraldehyde remained after disinfection, while grayish-black is evidence of residual OPA.

Handling with care
While flexible scopes require vertical storage, many measure 6 feet in length. Many nurses and techs might find them difficult to transport vertically without dragging them along the floor. Even a staff member tall enough to avoid this difficulty wouldn't be able to prevent the distal end and the control head, the most delicate part of the instrument, from swinging. If the control head should make contact with anything along the way to the OR or procedure room, the risk of a cracked lens, a crimped water irrigation nozzle or other damage is high.

That's why carrying a scope in a large, loose coil — with its angulation knob turned to the free-play position and its varying stiffness setting on neutral, in order to prevent damage to its internal controls — is necessary whenever you transport an endoscope. Scopes should also be transported only one at a time. Trying to carry 3 or 4 scopes tightly wound in a fist or looped around the shoulders and neck like a scarf is courting equipment damage.

While scopes can be carried outside of a container between the storage cabinet and the surgical suite, transporting them from there to central sterile is best undertaken in a basin. As before, they should be set for maximum flexibility and should not be coiled too tightly. Each basin should contain only 1 scope and its component parts. Sharps, forceps, scissors, wires or other items which might tear or puncture the insertion tube should not be placed in a basin or re-processed with a scope.

During transportation and in the sterile processing department, don't stack coiled scopes atop one another (though sealed-lid basins may be stacked) and don't place heavy objects on top of the scope, to avoid the risk of crushing the insertion tube or putting pressure on the angulation knob, which should be facing upward to prevent damage.

The fact that you've retrieved a scope from the storage cabinet doesn't necessarily mean that it's ready for use. Breaks in technique occur and accidents happen. That's why a thorough pre-procedure check for cleanliness and functionality is imperative.

After connecting the scope to the processor, a surgical team member should use suction and water aspiration to ensure there are no blocked channels or residual bioburden. The scope's air and water functions should be operational to let the physician insufflate organs for inspection and clear the lens if necessary.

Visual inspection of the endoscope to detect any kinks, bends or defects in the insertion tube is important not only before the procedure but also after reprocessing and even during the case. A physician's maneuverings of the scope will occasionally and inadvertently allow the slack to drop and bend at an angle, which can cause damage to the scope. Keeping an eye on the scope and alerting the physician to such a situation can prevent damage from occurring. Similarly, an assistant who notices resistance while passing a tool through the biopsy channel should notify the physician to a possible kink or bend in the scope, inside or outside of the patient, to prevent the possibility of a tear and fluid invasion.

A pre-procedure check for handling, by testing the responsiveness of the angulation knob which controls the direction of the distal tip, and for visual quality, by setting the white balance in accordance with the manufacturer's directions, can spare physicians a difficult procedure caused by failing controls or inexact output.

Unfortunately, aberrations discovered as a result of a pre-procedure check often leave the user with no choice but to isolate the device for investigation or take it out of service and ship it out for repair. Still, it's important to know there's something wrong with a scope before a case begins. Consider the alternative, a scope that presents difficulties mid-case. An effort has to be aborted and another scope retrieved, prolonging the case. If it was a struggle to reach the cecum or transverse colon, the patient has to suffer through the process all over again.

Cleaning up
You can improve workflow by establishing protocols for surgeons and staff to follow after using scopes. Instructing physicians to place the scope in a basin once it's withdrawn and not just leaving it next to the patient can speed room turnover. And, since bioburden can dry quickly in a long-lumened instrument, reminding staff to aspirate detergent and water through the scope's channels immediately after its use lends invaluable assistance to the reprocessing staff (see "Cleaning Cannulated Devices" on page 76).

At one time, sterile processing techs brushed, flushed and irrigated a scope's channels manually. Now some are using automatic endoscope reprocessors that claim to enable brushless cleaning. There's an argument to be made that a scope whose FDA approval was based on its proper cleaning with specially designed brushes and accessories should always be reprocessed in that manner, or else you face the risk of liability. But in the end, keep in mind that no matter which method of reprocessing you're using, manufacturers' directions are gospel, any cleaning accessories used should be in good order to prevent internal damage and reprocessed themselves to prevent cross-contamination risks, and scopes should be flushed with alcohol and air at the end of the process to clear the channels of residue.