Insertion tubes that house very narrow and delicate channels. Angulation control wheels, locking mechanisms and auxiliary water channels that are difficult to clean. Is it any wonder flexible endoscopes are a challenge to reprocess? Luckily, in June of last year the American Society of Gastrointestinal Endoscopy and Society for Healthcare Epidemiology of America updated their endoscope reprocessing guidelines for the first time since 2003. Let's look at the takeaway lessons from 7 key topics covered in the document.

1. Pre-clean
What the guideline says: Pre-cleaning should be performed at the point of use, before bioburden has an opportunity to dry and before complete decontamination. Point-of-use pre-cleaning should remove visible debris by wiping the exterior of the endoscope with appropriate detergent solution and aspiration of a large volume of detergent.

Be sure to wipe down the insertion tube with detergent, even if it's not visibly soiled. Aspirate detergent through the biopsy channel, even if the secretions in the suction canister look clear. Flush the auxiliary water channel, even if it went unused during the procedure. If you used the auxiliary channel and flushed it thoroughly, it still needs to be pre-cleaned. Failure to perform any of these steps immediately after a procedure will potentially leave infectious material on and in the endoscope. These secretions may dry very quickly, making the endoscope more difficult to clean if reprocessing is delayed.

2. Manual clean and leak test
What the guideline says: Before manual or automated high-level disinfection, meticulously clean the entire endoscope, including valves, channels, connectors and all detachable parts. Disconnect and disassemble the endoscope as far as possible and completely immerse the endoscope and components in an appropriate detergent that is compatible with the endoscope, according to the manufacturer's instructions. Flush and brush all accessible channels to remove all organic and other residues. Repeatedly actuate the valves during cleaning to facilitate access to all surfaces. Clean the external surfaces and components of the endoscope by using a soft cloth, sponge or brushes.

Manual cleaning of an endoscope is the cornerstone of endoscope reprocessing because it reduces bioburden on the instrument's surface and internal channels. Automated endoscope reprocessors (AERs) are becoming quite sophisticated and technologically advanced, challenging the traditional methodology of reprocessing. While these improvements are certainly welcome, as patient advocates you must be certain that these developing technologies are equivalent to the manual cleaning steps needed to reprocess an endoscope.

Leak testing, a mandatory element in the reprocessing of endoscopes, will detect damage to the interior or exterior of the endoscope. Perforated surfaces or channels of an endoscope are an infection control risk and exposure to fluid will damage the internal components of the endoscope. Leak test all endoscopes according to manufacturer's recommendations prior to reprocessing. Be certain to remove detachable parts such as suction, air/water valves and biopsy port caps, and ensure angulation control wheels and stiffener controls are in the free and unlocked position. Prepare a basin or sink with fresh water without enzymatic detergent that's deep enough for the entire endoscope to be completely immersed without tightly coiling the instrument. Do not reuse the fluid.

3. Follow manufacturers' directives
What the guideline says: Ensure that the endoscope and endoscope components can be effectively reprocessed with the AER (the elevator wire channel of duodenoscopes, for example, is not effectively disinfected by most AERs and this step should be performed manually). Obtain and review model-specific reprocessing protocols from both the endoscope and the AER manufacturers and check for compatibility.

Manufacturers of endoscopes and AERs have validated reprocessing instructions for the instruments and units they manufacture. The instructions must be followed without deviation to ensure endoscopes are properly reprocessed after each procedure. There are no shortcuts.

Materials compatibility is crucial during endoscope reprocessing, and that compatibility is twofold: The disinfectant solution must be compatible with both the endoscope and the AER. Though a disinfectant may be cleared for the disinfection of endoscopes, it may not be compatible with the specific endoscopes you use, resulting in damage to the exterior surface of the instruments, their internal components, or both. This may lead to costly and easily avoidable repair costs. Likewise, the AER may not be compatible with the disinfectant you choose, leading to breakdown or malfunction of the unit, unneeded repair bills and the possibility of an improperly reprocessed endoscope being used during subsequent procedures.

AER manufacturers should readily supply a list of endoscopes that are validated for reprocessing in their devices. When faced with questions about the capabilities of your unit, don't hesitate to ask the manufacturer for guidance.

4. Handle with care
What the guideline says: During endoscope transportation, an open container can suffice for transport to immediately adjacent reprocessing rooms, but fully enclosed and labeled containers or bags should be used for transportation to distant reprocessing areas. Place the endoscope and endoscope components in the AER and attach all channel connectors according to the AER and endoscope manufacturers' instructions to ensure exposure of all internal surfaces with the high-level disinfectant solution. If an AER cycle is interrupted, high-level disinfection or sterilization cannot be ensured; therefore, the cycle should be repeated.

Transport scopes to the reprocessing room in a way that prevents any potential for staff exposure to biohazardous matter. Transportation must also be completed in a way that minimizes the opportunity for inadvertent damage to the endoscope.

Don't treat your AER like a dishwasher, throwing in endoscopes haphazardly and slamming the lid shut. Follow AER manufacturer directions to the letter and pay careful attention to how endoscopes are handled throughout the reprocessing process. The proper placement of endoscopes in AERs prevents damaging their delicate components and ensures proper reprocessing. Avoid positioning the endoscope in such a way that crimps or bends the insertion tube, which could cause undue strain on the angulation wheels.

Each cleaning adaptor in an AER has a manufacturer-tested function that should not be altered. Monitor the adapters for damage and normal wear and tear, and replace them as needed.

5. Inspect carefully
What the guideline says: Visually inspect both endoscopes and reusable accessories frequently in the course of their use and reprocessing, including before, during and after use, as well as after cleaning and before high-level disinfection.

Conduct a thorough inspection of endoscopes during each reprocessing cycle in order to test the functionality of the angulation wires and catch problems or damage to the instruments that could impact their safe use. Regular inspections will help you detect minor crimps in the insertion tube or biopsy channels that could hamper the passing of accessory devices during procedures. Performing such close inspections will assist in the discovery of problems before endoscopes are placed back into service for use on another patient.

6. Test high-level disinfectants
What the guideline says: Perform routine testing of the liquid high-level disinfectant to ensure at least the minimum effective concentration (MEC) of the active ingredient. Check the solution at the beginning of each day of use (or more frequently). If additional liquid high-level disinfectant is added to an AER, the reuse life should be determined by the first use/activation of the original solution.

Discard disinfectant solutions when their recommended useful life has expired or they fail to meet MEC testing. Monitor the disinfectant during each reprocessing cycle by following the manufacturer's instructions for testing. Many of the tests are time-sensitive and improper results may be obtained if directions are not followed exactly. Be sure to use the disinfectant manufacturer's recommended test strip for monitoring the MEC, and document each MEC test result in a logbook.

7. Train your staff
What the guideline says: Personnel assigned to reprocess endoscopes should receive device-specific reprocessing instructions to ensure proper cleaning and high-level disinfection or sterilization. Competency testing of personnel that reprocess endoscopes should be performed and documented on a regular basis. Temporary personnel should not be allowed to reprocess endoscopes until competency has been established.

Conduct ongoing continuing education to ensure your staff is fully informed and up to speed on current endoscope reprocessing standards. Hang charts outlining proper endoscope care in the reprocessing area and randomly observe your staff's performance once a day to validate their performance.

Above all, don't take endoscope reprocessing lightly by assuming it's being done correctly. Conduct regular rounds in the reprocessing room to identify areas for needed improvement. Promoting endoscope reprocessing and infection prevention principles will maintain your staff's focus on keeping instruments working properly and patients safe. You'll also show the reprocessing techs that you're interested in the work they perform and how well they perform it.