HANDS ON Automated endoscope reprocessors are sophisticated machines, but don't fully replace the importance of expert manual technique.

Today's automated endoscope reprocessors are sophisticated machines that do it all — pre-clean, test for leaks, alcohol flush for improved drying — to get instruments back into the hands of your physicians sooner and safer. So what should you look for when shopping for an AER that's right for your facility? That depends on several factors.

TECH TIP Pay attention to how easily endoscopes are loaded into the AER to prevent damage and ensure proper reprocessing.

1 The disinfectants
Many GI facilities are opting for ortho-phthalaldehyde (OPA) over glutaraldehyde because of OPA's greater disinfecting effectiveness and significantly shorter exposure time. Most of the new automated reprocessors employ oxidative agents such as peracetic acid that are more expensive options than simple aldehydes, but also more effective as germicidal solutions. In general, oxidative chemistries offer a better kill and less exposure time than aldehol-based solutions.

AERs with the capability to heat the high-level disinfectant could lead to quicker scope reprocessing. For example, OPA heated to above 25 ?C slashes cycle times to 7 minutes, compared to 12-minute cycles with non-heated OPA.

You may be locked into using a proprietary disinfectant, depending on the unit you purchase, so check with AER vendors before making a final decision. Also confirm that the type of endoscopes you use can be disinfected in the reprocessors you're considering. The AER manufacturer is responsible for providing this information, but it doesn't hurt to check with scope manufacturers to ensure an AER's detergents and disinfectants are compatible with their products.

Finally, look for machines with single-cycle disinfectant capabilities. That's a big key in the future of automated endoscope reprocessing, and the direction it's moving toward to ensure infectious material doesn't accumulate in reusable disinfectants. Of course, expect units featuring single-cycle disinfectants to be a bit pricier. In my mind, however, the increased safety and peace of mind they afford are worth the added expense.

2 Cycle time
Many factors impact the amount of time it takes an AER to reprocess endoscopes, including:

• Leak testing. There are no shortcuts to proper leak testing. Your techs must carefully examine each scope, a process made easier with the automated testing available on newer machines. Automated tests are more sophisticated than manual inspections and can find leaks that reprocessing techs may miss. Automatic leak testing essentially takes human error out of the equation, eliminating the risk of trace amounts of fluid remaining in a scope, which can cause damage resulting in one of endoscopy's costliest repair bills.

• Cleaning. Pre-wash cycles ensure that any debris left over from the scope's pre-cleaning has been removed before the rinse cycle and high-level disinfecting. Two units presently on the market claim to eliminate the need for manual cleaning before the reprocessing cycle. Unfortunately, a multisociety endoscope reprocessing position paper and guidelines issued by the Society of Gastroenterology Nurses and Associates don't endorse the brushless claims. This presents an excellent opportunity for gastroenterology and endoscopy societies to collaborate with vendors on validating the assertions.

• Drying. Newer units incorporate an alcohol flush at the end of the reprocessing cycle to promote drying and keep the scope's channels clear of residual water that could cause harmful bacteria to grow while the instruments are stored between uses.

• Capacity. The number of endoscopes a unit can house is vitally important because you want to get the most bang for your reprocessing buck. Some newer machines can reprocess 2 scopes at a time in a single basin (depending on the size of the endoscopes), while other units can reprocess 2 scopes independently in separate basins. Be sure the capacity of the unit you choose meshes with your scope inventory and caseload.

3 Footprint and utilities
Some AERs are large units taking up considerable floor space. Others are more compact, countertop units. A new machine's size is paramount to consider, especially if you're trying to retrofit its footprint to an existing reprocessing room.

Also ask the manufacturer of the unit you're interested in to provide specific details of the device's utility requirements, and compare them to your facility's current output. Some of the newer units have strong pumps that empty the reprocessing basin more swiftly, so consider if your plumbing's drainage capabilities can accommodate how the machine is evacuated. Do you need to run a dedicated power line to the reprocessing room or is standard electrical current adequate? Do you need to install a breaker box with a power-killing switch near the new unit? Will the AER run on tap water? Does the unit's water have to reach a certain temperature? If so, you may need to add mixing controls to your facility's plumbing. You may also have to test the hardness of the water and possibly add a water softner. Keep in mind that water temperature can fluctuate with the seasons. My facility ran into trouble, having tested our water supply during the summer months, then discovered the cold Cleveland winters dropped the temperature considerably.

NUMBERS GAME Be sure an AER's capacity meshes with your scope inventory and caseload.

4 Recordkeeping
Advancing AER technology lets you link each reprocessing cycle to an individual tech and specific endoscope. That information is documented in electronic records or on paper reports printed at the end of each day. Having individual scope reprocessing data recorded at the completion of every cycle ensures disinfection parameters have been met. Mining that data is hugely valuable in improving the efficiency of your reprocessing department — you can compare when procedures end and scope reprocessing begins or how quickly scopes are removed from units when cycles are completed — and drilling down during investigations in the event of possible cross-contamination exposures.

Audible alarms, which alert you to mechanical mishaps or user errors before they impact the proper completion of reprocessing cycles, go hand-in-hand with electronic records or hard copy printouts to ensure scopes are properly reprocessed. For example, some AERs feature alarms that sound if the disinfectant's minimal effective concentration isn't reached or a connector isn't properly attached to an endoscope's channel.

5 User-friendliness
How easy is the loading and unloading of endoscopes? Do reprocessing techs have to bend over and reach into the unit to pull out a drawer or stand on their toes to load instruments into the basin? How quickly are scopes connected to the unit? The traditional method calls for techs to attach a unit's connectors to an endoscope's various ports. A newer AER, however, employs "boot" technology to simplify the process. The boot covers the scope's control head; only the auxiliary water flushing port has tubing that needs to be individually connected. That feature eliminates the possibility of a connector being improperly attached to the scope or falling off during the reprocessing cycle. In addition, attaching a single boot to the scope instead of numerous individual connectors will, over time, lead to greater reprocessing efficiency.

6 Cost
Ten years ago, you'd expect to spend about $8,500 for a rudimentary AER with basic functions. But as technology has improved, the machines have become more complex, and therefore more expensive. Today, spending upward of $60,000 for more advanced units is not uncommon.

You may be shocked at reprocessing's true costs, such as filter changes and preventive maintenance, which can easily eat away at your bottom line, but don't always opt for the least expensive option in order to save some money on the front end. What may appear to be the more economical choice might not be when you factor in the cost of the disinfectant the machine uses. Keep in mind that the more expensive disinfectants and high-tech AERs could lead to faster cycle times, quicker scope turnarounds and potentially adding more revenue-producing cases to your facility's schedule. In the end, you get what you pay for. The more expensive reprocessors cost more because they do more for you. While pricier, the newest options are ultimately worth the added investment.