The Essentials: Flexible Endoscope Reprocessing

Four areas SPD leaders must regularly review with their teams.

Technologies such as automated endoscope reprocessors (AERs), borescopes and specialized drying cabinets help staff at busy GI centers seamlessly perform a steady stream of complex reprocessing tasks that keep scopes clean, high-level disinfected and safe for use with the next patient.

Adequately training the staff who use those technologies and standardizing the practices for their use, however, is what makes the difference for success, according to Dyan Darga, MSN, RN, CGRN, NE-BC, who spent 20 years working in multiple endoscopy leadership roles at several academic medical centers. Ms. Darga serves on the Association for the Advancement of Medical Instrumentation (AAMI) ST91 working group, which updates evidence-based practices for the care of flexible and semi-rigid endoscopes.

Here are four important areas Ms. Darga suggests outpatient leaders target to catch steps that can be missed and to strengthen practices that will help keep flexible endoscopes safe and ready for use.

1. Prioritize point-of-use cleaning

The initial treatment of scopes in the procedure area prior to reprocessing, often referred to as point-of-use (POU) or precleaning, is an area that is often full of practice deficiencies. Make sure your teams are following these three evidence-based practices at the bedside.

• Correctly clear the channel. Make sure the air/water cleaning adaptor — often called a “credit card” — is used to clear channels according to the scope manufacturer’s instructions for use (IFU). “This is a step that staff have a tendency to not be aware of or neglect doing,” says Ms. Darga.

• Document the time POU treatment was completed. The more time that passes between POU treatment and the beginning of reprocessing, the more likely an extended soak time will be required. Staff should follow the manufacturer’s IFU about recommended timeframes to inform this decision. If no timeframe is specified, AAMI ST91 recommends that manual cleaning occur within an hour. This is known as the “golden hour” to prevent difficult-to-remove bioburden from adhering to interior channels.

• Educate OR teams about POU practices. All staff performing POU treatment at the bedside should be appropriately trained in proper techniques, but this doesn’t always happen, says Ms. Darga. “I often see incomplete or no POU cleaning happening in the OR where large staff size and staff turnover can make it a challenge from an educational standpoint to have everyone properly trained,” she says.

2. Make cleaning verification standard

Cleaning verification, once only a recommendation, is now an AAMI ST91 requirement, says Ms. Darga. “Cleaning verification and visual inspection should go hand in hand,” she says. The qualitative and quantitative measures used in the verification process determine the adequacy of the manual cleaning that was just performed and ultimately determine whether the scope is ready for high-level disinfection or sterilization.

• Verify, verify, verify. Qualitative measures typically test for protein, hemoglobin, carbohydrates or all three — and usually involve a test strip or vial that incurs a color change when positive. Quantitative tests such as adenosine triphosphate (ATP) involve use of a swab and a handheld meter that generates a numerical result within seconds.

Any endoscope whose test results exceed the threshold number must be manually cleaned again and re-examined for defects such as nicks or scratches that can make them more difficult to clean.

• Document the results. Just as it is no longer optional to verify cleaning, it’s also not optional to document cleaning verification results. Qualitative test results must be logged and include the date and time of the test, the serial number of the scope and the result of the test. If a positive test is noted, actions that are taken to remedy it must be logged as well. Quantitative test results typically are automatically logged electronically.

GETTING THE JOB DONE

How to manage more than 16,000 annual procedures

BEYOND CLEAN A sterile processing professional works on an endoscope at Dallas Endoscopy Center.

Dallas Endoscopy Center handles more than 16,000 cases per year. Here’s how it manages that caseload in an efficient and safe fashion, according to Administrator Susan Cheek, CPA, CHCC, CASC.

• Sterile processing staff rotate into scope processing rooms daily to ensure all techs are trained, stay on top of their skills and pay close attention to detail.

• Two techs work at any given time — one on the dirty side of the room and one on the clean side — to ensure continuous flow and minimize time lapse.

• Scopes are tagged with the printout from the automated endoscope reprocessor (AER) that is attached to the clean scope so the tech in the procedure room can further confirm it has been processed correctly. This tag is signed off on and becomes part of the medical record. The number on the tags is verified against the number on the scopes.

• Every staff member who handles a scope is trained in manual and automated reprocessing in accordance with manufacturer instructions.

• Scope technology questions that can’t be answered by a member of the team go directly to the manufacturer for answers.

—Carina Stanton

• Visually inspect the scope. This should be done in a standardized way during cleaning verification, ideally with the use of lighted magnification. The tech should observe the distal tip, control handle knobs, biopsy and valve port areas and any other areas of concern. If the inspection reveals rust, chips, scars, dents or tears, the scope should be sent out for repair.

A borescope is another tool that can be passed through the channels of an endoscope to provide a lighted, magnified view of the interior. “A common refrain heard when the use of a borescope is suggested is, ‘How do I know what I’m looking for?’” says Ms. Darga. “This is certainly a valid concern.” It’s also an area where technological innovations may play a pivitol role in the near future. In fact, AI software to assist users with interpreting borescope findings continues to develop, she says.

3. Reduce automated endoscope reprocessor errors

There are four frequent failures surrounding the operation of AERs that Ms. Darga encourages scope processing leaders to target during team training sessions.

• Know the IFUs – and follow them. This includes IFUs from the scope manufacturer, the AER manufacturer and the chemical manufacturer.

• Confirm the expiration dates for the chemicals in use. Make sure that the minimum effective concentration tests are performed and documented well.

• Check the tubing connections. This should occur at the beginning and end of every cycle. Sometimes a connector can become loose or get blown off and go unnoticed by the sterile processing technician. When this happens, a time-consuming repeat of the reprocessing cycle is required.

• Position AERs properly. AERs should be at least four feet away from your manual cleaning sinks to minimize dirty sink aerosols from contaminating the clean AER area.

4. Prevent risks during drying and storage of endoscopes

Scope contamination is a major concern throughout the drying and storage process for mulitple reasons, but it can be mitigated by these practices.

• Thorough drying prevents biofilm. If an endoscope is not thoroughly dried after HLD, it creates an environment where bacteria can multiply rapidly and turn to biofilm.

To prevent this, several professional societies specify the use of pressure-regulated air for a minimum of 10 minutes to dry scopes. This is in addition to the air purge cycle in the AER.

• Use lint-free or low-linting cloths to dry the exterior of the endoscope. Some organizations specify the application of single-use or sterile wipes. “The big takeaway here is to achieve complete dryness,” says Ms. Darga. “There are very effective products on the market to test scope dryness at the end of a cycle.”

• Track hang time. Teams need to be sure that each reprocessed scope does not exceed its maximum storage time, commonly known as hang time. Currently, there is no consensus among guiding organizations on this issue.

The Society of Gastroenterology Nurses and Associates is the only organization that suggests a maximum number of seven days of storage before a scope needs to be reprocessed. OSM