BRUSH AND FLUSH Thorough manual cleaning is essential to prevent the formation, and near-permanent residence, of biofilm in an endoscope's lumens.

The complex design of your endoscopes makes reprocessing them a challenging task, especially since the prescribed cleaning guidelines are always vulnerable to human error. Are you doing enough, then, to protect these instruments — and your patients — from a cross-contamination risk that can withstand even the rigors of proper, thorough and repeated high-level disinfection?

Beware of biofilm
Many gram-positive and gram-negative bacteria, including those that colonize the GI tract, have the ability to form a biofilm. This sticky microbial slime adheres to any surface, particularly a wet or damp one, and hardens into a protective coating for the bacteria it surrounds. Once a biofilm forms on a surface, it's very difficult to remove, and because it resists the bactericidal activity of high-level disinfection, it lets the organisms inside live on.

Bioburden and residual organic material left behind on improperly or inadequately reprocessed surgical instruments may spark biofilm formation. This can be particularly common, and particularly problematic, in the multiple ports, channels and other intricate, difficult-to-reach-and-clean inner components of endoscopes.

From a hardware perspective, there's no evidence that biofilm damages or shortens the usable life of a scope. But a coating of bacteria sequestered in the recesses of a lumened device presents a cross-contamination risk to the next patient in line to be exposed to that device.

More bad news: As there's no entirely accurate, readily accessible method of biofilm detection, you likely have no way of knowing if your scopes are contaminated or guaranteeing that they're not. The truth is, the battle against biofilm is not 100% winnable, but vigilance remains necessary. So meticulous prevention efforts are the key to reducing the risk of biofilm-mediated post-op infections. There are 2 things you can begin doing today to get you moving in the right direction — standardize your reprocessing protocol and correct your reprocessing techs' errors.

Step 1: Standardize your reprocessing protocol. Industry organizations and experts agree that adequate cleaning and reprocessing, which can disrupt the formation of biofilm, depends on these 3 practices:

• Mechanical cleaning. Are your OR staffers pre-cleaning scopes after use? Are your reprocessors' manual brushing efforts adequate?
• High-level disinfection. Are they using enzymatic detergents effectively and automated endoscope reprocessors (AER) properly?
• Post-processing. Are they handling, inspecting and storing scopes correctly?

Ensure that your sterile processing team members are trained in and compliant with scope, disinfectant and AER manufacturers' instructions for use and society guidelines, and elevate their importance in your facility's infection prevention efforts.

Step 2: Monitor the process and correct your techs' errors. While the complex designs of some endoscopes can resist or limit thorough disinfection and have played a part in cross-contamination incidents, many more outbreak investigations have cited such basic missteps as delaying, overlooking or truncating mandated reprocessing steps — in short, human error — and these can easily contribute to biofilm formation.

For example, in the wake of an outbreak of multi-drug-resistant Pseudomonas aeruginosa infection associated with contamination of bronchoscopes and an endoscope washer-disinfecter at a French teaching hospital, a 2010 study found that the pre-washing or mechanical cleaning stage may have been delayed, and that the scope hadn't been adequately dried before it was reused. When you expect reprocessing to be delayed, it may be advisable to soak the scope in a manufacturer-approved enzymatic detergent until you can clean and disinfect it. However, a lack of recommendations or guidelines on the effects that extended soaking has on scope integrity or internal or external bioburden suggests that the better approach is to make every effort to complete endoscope reprocessing in a timely manner. Another investigation highlighted an AER's inability to achieve adequate flushing pressures, pointing to a need to manually flush scopes.

Many cracks to fall through
Ultimately, any number of errors can occur in a busy practice, each with potentially deadly implications. A recent study analyzed endoscope-reprocessing lapses nationwide that had been published in medical literature, the news media and governmental reports between January 2005 and June 2012. The study listed incidents in which reprocessors and other scope handlers:

• didn't comply with established, published guidelines,
• failed to pre-clean endoscopes before reprocessing,
• failed to perform or allow an adequate duration of high-level disinfection,
• used expired disinfectants,
• let endoscopes dry before they were cleaned,
• inadequately brushed channels or skipped channel-cleaning entirely,
• improperly cleaned the elevator component of duodenoscopes,
• improperly stored contaminated endoscopes,
• incorrectly programmed AERs,
• were unaware of, or failed to report, malfunctioning AERs, and
• insufficiently documented staff competencies to perform endoscope processing.

Although the pace of reprocessing at a busy endoscopy practice can be overwhelming, there's never an excuse for lapses that could expose patients or personnel to dangerous health care-associated pathogens.