TOUGH TASK It's a big challenge to consistently reprocess GI scopes.

By their very design, flexible endoscopes are difficult to clean. Long lumens that you can't visualize. Narrow diameters that can trap the biological material they encounter when they access highly contaminated areas of the body.

Studies have shown that up to 30% of flexible endoscopes remain contaminated after manual cleaning. If we don't promptly flush scopes after a procedure, debris can dry inside the lumens and become extremely difficult to remove. So the first step in cleaning is to flush all the channels immediately after the end of the procedure, to remove as much debris as possible before you take the scope to the processing area. There, you must leak-check the scope to ensure the device isn't damaged. This is just the beginning of the scope's long reprocessing journey. The more you can standardize the many steps along the way, the better.

Enzymatic detergents or enzymatic detergent-disinfectants help break down proteins and other biological debris in the lumens of the scope, but many things must be done just so before, during and after the soak. You must mix the enzymatic product per label instructions, soak the scope for the indicated amount of time and change the solution after each scope or per label instructions. Used solution may not work as well as fresh solution.

You must take off all the removable caps and ports so that you can thoroughly clean and soak them with the scope. When scrubbing the channels, you must you use the appropriate brush(es) — make sure those brushes are in good shape to scrub all the internal surfaces of the lumens.

Disposable brushes are designed for a single use and may not be used on more than one scope. Reusable brushes must be intact and high-level disinfected between uses. Discard them if the bristles are worn or there are any sharp wires that have come loose that could tear the lumens. Once you've brushed the scope thoroughly — a good sign you've done so is when you don't obtain any more debris — it's time to flush the lumens with water. Then you must blow the channels with air to remove any remaining water, so as to not dilute the high-level disinfectant (HLD) solution.

Test the HLD for potency before each use. Follow the instructions provided by the HLD solution and the test strip manufacturers. You place the scope in the HLD solution along with the cleaning brush(es), if reusable, and all the accessories, per scope manufacturer instructions. You must flush lumens with solution, ensuring there are no air bubbles. Use a timer to ensure that the soak time adheres to the time listed on the HLD label. Timing begins once the last item is placed in solution. If you place additional items in the solution after you've set the timer, reset the timer to the required soak time. Nothing can float in the HLD; all items must be completely submerged. Don't process floating items such as syringes in this manner, as they'll not be high-level disinfected if floating. Triple-rinse scopes to ensure you've removed all the HLD. Some automatic endoscope reprocessors (AER) do this automatically.

SOAKING THE SCOPE Enzymatic detergents or enzymatic detergent-disinfectants help break down proteins and other biological debris in the lumens of the scope.

CONNECTED Automatic endoscope reprocessors automate most of the scope-cleaning process. Correct connections between the scopes and the AER are key.

Automate the process
AERs essentially automate a good portion of the scope-cleaning process, but it's important to look at exactly what the AER does so that the technician performs the steps that aren't covered. In general, he'll still need to manually perform immediate flushing, soaking in an enzymatic product and thorough brushing.

It's critical that you properly connect the endoscope to the AER. This connection varies by type of scope and type of AER. Incorrectly connecting the scope can lead to inadequate disinfection, putting subsequent patients at risk for infection. Some AER manufacturers provide a quick-check guide attached to the machine to assist in proper connection. Absent this, the connections should be posted near the AER for worker reference. When possible, post the cleaning procedure in the area used for scope processing.

AERs can heat the HLD solution to the HLD manufacturer's required temperature and allow for the shortest possible soak time. Basins of HLD usually can't be safely heated, meaning a longer soak time. Different HLD products have different soak times. Always read the label and follow the directions. Make sure that purchasing doesn't order something "similar" that might be a few cents cheaper, but has a longer soak time. Consistency of products and processes improves outcomes.

Not visible to naked eye
The design of flexible scopes means that debris can "hide" — the rinse before soaking may be entirely clear, yet the lumen may contain debris. Products on the market can detect biological matter by identifying ATP (adenosine triphosphate), which is a building block of DNA. Several manufacturers offer ATP testing products designed specifically for long, flexible scopes. You run a long wire with a swab on the end through the channels. After you remove the wire, you add a reagent to the swab. A relative light units reading above the cutoff indicates the presence of ATP, meaning biological contamination is present. One of the drawbacks of this method is that it can't distinguish between live organisms and dead ones. There may be a small amount of debris, but no live bacteria that might harm a patient. But it certainly is a method that you can use to monitor scope cleaning and worker performance.

Nothing scares me more than going into a facility and having someone say, "We love it when Stanley is doing the scopes. He can turn them around in less than 12 minutes!" If the high-level disinfectant in use has a label instruction of a 12-minute soak time, this means some or all of the process is being done incorrectly. There can be time pressures. Ideally, you'll purchase additional scopes to keep the patient flow going and allow for proper processing. The key is getting clinic and hospital administration to understand how critical it is to process each and every scope correctly — and that takes time.

Standardizing makes sense
Standardizing the process is a good idea to ensure steps aren't skipped or shortchanged. Purchasing a single brand of scope can also help, as there will be fewer differences in the process between scopes from the same company. Before purchasing a new scope, evaluate the cleaning processes to be sure they fit in with your existing physical plant and cleaning procedures. A scope with an entirely different process begs for trouble. Make sure purchasing knows not to change high-level disinfectant products just to save a dollar or 2. If the new product has different testing or soaking requirements, and staff are unaware of this, improper processing may result.

To keep everyone at the top of their game, have competency-based training for each employee involved in scope processing, with separate evaluations for each different scope in the inventory. Keep written policies and procedures up to date. Perform periodic monitoring of compliance after training, at least annually, and when changes in the process or products occur.