IT TAKES TIME Let your surgeons and OR staff know how long it takes to properly reprocess a scope.

There's no room for cutting corners when you're reprocessing flexible GI endoscopes. Here's what a day in the life of your endoscopes should look like.

Step 1: Pre-cleaning
Starting at the point of use, your first priority in the scope turnaround process is to pre-clean the instrument as soon as possible after a case has concluded. Tableside pre-cleaning gives your reprocessing team a head start on this front. The scope's exterior surfaces should be rinsed and sponged down. Its channels should be flushed with an enzymatic detergent solution as an initial precaution against gross debris that might remain inside. And the job should be done, and done consistently, by your OR staff.

This may seem burdensome to time-crunched nurses and techs, notes Karen Swanson, LPN, CSPM, CFER, sterile processing manager at Connecticut Children's Medical Center in Hartford, Conn., and chair of the Certification Board for Sterile Processing and Distribution (CBSPD). 'There's a lot of equipment to clean and disinfect. They know the room must be turned over quickly. In a hurry, people may not be pre-cleaning at bedside,' she says.

But sending untreated scopes to reprocessing is a prescription for damage and danger, especially since they might not get immediate attention once they arrive there. A lack of pre-cleaning will surely complicate the rest of the process.

'It's like leaving dirty dishes in the sink. If you let them go too long, they dry out and it's difficult to get the soil off,' says Chris Lavanchy, engineering director of the health devices group at the ECRI Institute in Plymouth Meeting, Pa. Inadequate endoscope reprocessing topped the non-profit research firm's annual list of health technology hazards this year. 'Material that dries on scopes will be nearly impossible to remove, especially in lumens. It's difficult to get into those and brush those off.'

Once pre-cleaning is completed, coil the instruments into a container to prevent their contact with anything else while they're transported to SPD.

EXTRA PRECAUTION Even if you use an automated endoscope reprocessor for high-level disinfection, the FDA recommends meticulous manual cleaning.

Step 2: Cleaning
Once the scopes reach the decontamination room, time is an issue. In Ms. Swanson's view, 2 questions weigh over the process. Can your techs prioritize scopes, so they don't wait unreasonably long for cleaning? And, do your physicians know exactly how long it takes to properly reprocess a scope, so their demands for turnaround don't undermine patient safety?

'When [reprocessors] are under the gun, it's easy for them to take a shortcut and stray from the manufacturers' instructions for use,' she says. 'People have to know and really understand the importance of cleaning scopes.'

They have to put in the elbow grease to get the job done, too. After a round of inspecting and leak testing the scope comes the rigorous, repetitive process of manual cleaning. Channel brushing and filtered water flushing scrubs and rinses out the bioburden that the pre-cleaning loosened.

How long should a tech brush and flush? For as long as it takes, says Mr. Lavanchy, depending on your scope model and the skill of your tech. 'It must be done over and over again until there is no visible debris. The endpoint is, you're convinced you've done a quality job,' he says. 'If your inventory is lean, there may be pressure to turn around scopes as quickly as possible, but then the results would not be as thorough.'

In addition to time, make sure your reprocessors have the necessary tools. A full complement of personal protective equipment, to shield them against biohazards and chemical agents. The right sized brushes, detergents and fresh supplies for each scope to avoid re-contamination. The scope manufacturers' instructions for use, to ensure familiarity with technical specifications. ('They are very detailed and if so much as 1 step is overlooked, all the cleaning is for naught,' says Mark Duro, CRCST, FCS, director of sterile processing operations at New England Baptist Hospital in Boston, Mass.) And, if possible, certification in the field.

While only New York, New Jersey and Connecticut currently require SPD employees to be certified, the designation can help to ensure compliance with standards. 'It's important that we ensure that the staff doing the job have been trained on the devices, are professionals, and have the insight and critical thinking skills gained through certification and continuing education,' says Mr. Duro.

The CBSPD, known for its Certified Sterile Processing and Distribution Department Technician credential, which establishes competency in surgical instrument reprocessing, now also offers a specialized Certified Flexible Endoscope Reprocessor credential for qualified staff (sterileprocessing.org/gi.htm).

'If your facility is routinely processing GI scopes, it should be considered,' says Ms. Swanson. 'You're not going to find administrators who want to clean scopes, or who know them in and out and will get up to their elbows to demonstrate. But they understand there is a lot of complexity in cleaning, and want to make sure their staffs are carrying it out correctly.'

Step 3: High-level disinfection
The brushing and flushing of manual cleaning are followed by chemical action, as the scope is immersed in a tub or sink filled with a liquid germicide solution. Since effective high-level disinfection depends on specific concentrations, temperatures and immersion times, it's important to adhere to the instructions provided by both the chemical's and the scope's manufacturers.

Alternatively, you might consider installing an automated endoscope reprocessor (AER), which streamlines high-level disinfection. 'By connecting a few fittings to the scopes, you've got thorough channel flushing and continuous leak testing at the push of a button,' says Ms. Swanson. The FDA has even cleared some AER makers to market the claims that their devices include cycles that can replace the need for manual cleaning. Keep in mind, however, that 'no AER can make up for a failure to pre-clean the scope at the point of use,' she says.

Besides bringing convenience to high-level disinfection, AERs also safeguard the process. The machines will halt their operations and notify the user if they detect an error in a cycle or a flaw in a scope, and they document their results to verify the successful completion or the interruption of a job, says Ms. Swanson. Their contained process also limits employees' exposure to the disinfectant chemicals.

Recent superbug outbreaks linked to cross-contamination from difficult-to-clean duodenoscopes have raised a big question: Is high-level disinfection sufficient for reprocessing scopes? The short answer, according to experts: Maybe not, but in order to sterilize them you'll need either more time or more scopes.

High-level disinfection is the industry standard for reprocessing flexible endoscopes, as dictated by the Spaulding Classification System. But epidemiological experts have pointed out that the margin of safety may be narrow, depending on how effectively reprocessing's steps are routinely conducted. 'There are circumstances where traditional cleaning and high-level disinfection will still leave a microbial load,' says Mr. Lavanchy. 'If we can't get them 100% clean, maybe that's justification for hitting it with the strongest process, sterilization.'

At present, the most effective sterilization option that scopes can tolerate is ethylene oxide (EtO) gas. However, a limited number of facilities have ready access to EtO treatment, given its toxicity risks and ventilation requirements, and the process takes 24 hours to complete. While liquid chemical sterilants are available, the research into their effectiveness is not as well established, says Mr. Lavanchy, and manufacturers have not yet developed a scope that can stand up to steam sterilization.

Step 4: Storage
When you're retrieving a scope for a case, you presume that it's free of microbes and safe to use on a patient. Hand on the same assurance when you're returning it to the storage cabinet. After either manual or mechanical high-level disinfection, while wearing freshly donned gloves and barrier protection, flush the scope's channels to make sure they're dry. First with compressed, filtered air to drive out moisture, then with alcohol to evaporate any that remains and to prevent microbial growth.

At this point in the process, 'colony counts may be low, but if scopes are stored moist, they may multiply,' says Mr. Lavanchy. 'Hanging a wet scope creates a hospitable environment for bacterial growth.' Various tests are available for monitoring scope cleanliness through the detection of organic residue, an indirect marker of microbial presence. Since it takes time to conduct these tests, though, and may sideline your inventory, it's likely not practical to test every scope after every use for an up-to-the-minute status report. OSM