PROCESS OF PRECAUTIONS Any residue left behind after initial cleaning will affect the outcome of automated reprocessing.

A few years ago, an industry expert made the case that one of the practices many of our GI endoscopists swear by to improve visualization during colonoscopies — diluting and injecting the suspension form of simethicone into a patient's colon — could jeopardize proper scope reprocessing. Was it possible our scopes weren't fully clean? Had we been putting our patients at risk? Had we been damaging our scopes? Were we cleaning effectively enough to remove the residue? The many questions led to an examination of our high-level disinfection process. Here's how we did it and what we learned.

Targeting the issue
Although flexible endoscopes don't require the sterilization that items entering sterile tissue do, they do come in contact with mucous membranes and non-intact skin, so they require the friction of manual cleaning and high-level disinfection via a soak pan or automated endoscope reprocessor. Eliminating bioburden — including simethicone residue — from their lumens, ports and channels is a critical infection prevention issue.

The manufacturer's directions for our flexible endoscopes didn't mention simethicone, so I called the manufacturer directly to square their findings against the speaker's advice. The letter their research department sent me made no such prohibition regarding the use of simethicone. They'd received reports from customers that its use in high concentrations made the removal of residue from the endoscope and water container difficult, even with strict adherence to the manufacturer's reprocessing instructions. Because failing to remove this residue during the manual cleaning stage of reprocessing could adversely impact the end result, they recommended that those who used simethicone during endoscopy use the lowest practical concentration.

Despite the mixed signals from the industry expert and the scope manufacturer, finding out whether our scopes had been thoroughly cleaned was important to our center because patient safety always comes first and we're very strict about the rules of proper reprocessing. We have to be confident in our practices and know we're doing things correctly. I wanted proof from a process, whether we were in the wrong or in the right. So I decided to run a quality improvement study to find out.

ELBOW GREASE The friction of manual cleaning is an all-important first step in the high-level disinfection of flexible endoscopes.

Collecting the data
Once I'd planned the project, I presented it at a staff meeting. It wasn't complicated. When our physicians used simethicone in a scope, we'd check the water channel for residue after our routine manual cleaning.

Not all of our endoscopists use simethicone in their cases, not all of those who do use it in every case, and all of them have varying case volumes. So we'd rely on the procedure room staff to let us know when the compound had been used, and a cleaning room tech would tag the scope to make sure it got checked. We have 3 techs working in the cleaning room, so it wasn't difficult to maintain a uniform process.

The simethicone scopes would be manually cleaned, like every other scope, before we'd run the channel check test. A proper channel check involves using a syringe to inject 10ml of sterile, de-ionized water through the channel, followed by a flushing of air. The water is then collected in a clean plastic bag secured at the distal tip. Finally, a specially manufactured test strip is dipped in the water. The test strips are designed to identify the presence of 3 residual organic soils that often remain in the lumens of surgical instruments after use: protein, hemoglobin and carbohydrates. (According to their manufacturer, the strips can help you determine how well you clean your instruments, "but are not a substitute for vigilance in observation of the state of surgical instruments.") In about 90 seconds, they deliver their results.

After each channel check test, our techs would record the date, the pass-or-fail results, the scope number, doctor's name, the procedure it was used in and their initials in a logbook. The scope would then be cycled through the automated endoscope reprocessor. In the event of a failed test, we were prepared to run the scope through the AER, then send it back to the manufacturer for thorough cleaning and repair. If the failures mounted, we'd present the data at a physicians' meeting and halt the use of simethicone in scopes.

TIMELY TURNARONDS
4 Ways AERs Improve Scope Care

Automatic endoscope reprocessors get instruments back to procedure rooms sooner and safer, according to Jim Collins, BS, RN, CNOR, practice manager for the department of gastroenterology and hepatology at the Cleveland Clinic in Cleveland, Ohio. Here are a few of his reasons why.

1. Oxidative agents. Peracetic acid is a more expensive option than simple aldehydes, but also more effective as a germicidal solution. In general, oxidative chemistries offer a better kill and less exposure time than aldehol-based solutions.

2. Single-cycle disinfectant capabilities. This is 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.

3. Fast reprocessing times. Automated leak testing, pre-wash cycles (after proper manual cleaning of the scope), alcohol flushes for improved drying and the capability to reprocess 2 scopes at a time in a single basin (depending on the size of the endoscopes) or 2 scopes independently in separate basins can get scopes turned around faster.

4. Advanced recordkeeping. The ability to link each reprocessing cycle to an individual tech and specific endoscope to ensure reprocessing parameters have been met is hugely valuable information in the event of a cross-contamination investigation.

— Daniel Cook

Analyzing the results
We tested every flexible endoscope that saw simethicone for a year, from February 2012 through January 2013. Eleven of our physicians had used the compound in 140 scopes. One doc used it in 44 scopes during the study, another in only 1. Out of 140 scopes tested, none failed the channel-check test after the initial cleaning phase.

So it was that much more satisfying when I was able to report to the quality assurance and process improvement committee in February that the data showed overwhelmingly positive results and that no corrective action was necessary. Not to mention that my supreme confidence in our reprocessing staff's abilities was confirmed.