COILED AND SOILED Use of a contaminated endoscope may lead to patient-to-patient transmission of potentially infectious pathogens.

With their long, narrow lumens, right-angle bends and mishmash of springs, caps, valves and connection sites where bacteria can hide, flexible endoscopes might be the hardest instruments to clean. Even if your techs diligently follow manufacturers' instructions and professional guidelines for reprocessing, there's still a chance that viable microbes and biologic debris could persist on your endoscopes. This helps explain why there are more outbreaks of infection associated with endoscopes than with any other reusable medical device. It also strongly suggests that today's reprocessing guidelines and practices aren't sufficient to curb increasing GI scope-related outbreaks.

Some are now calling for a radical shift in scope reprocessing from high-level disinfection to steam sterilization. A leading proponent of this shift is infection prevention expert William Rutala, PhD, MPH. "Sterilization is the only way to unify reprocessing and reduce the infection risk," says Dr. Rutala, a professor in the division of infectious diseases at the University of North Carolina's School of Medicine. "Although the incidence of post-procedure infection remains very low, endoscopes represent a significant risk of disease transmission."

Sterilizable scopes by 2018?
Dr. Rutala will recommend to the U.S. Food and Drug Administration that it mandate that all GI scopes be sterilizable by 2018. A scope you could steam sterilize would be a "game-changer," says Donna Nucci, RN, BSN, CIC, an infection preventionist at Yale New Haven (Conn.) Hospital. "Nobody is going to get to zero microbial contamination all the time. Even if you're following the new CDC guidelines, that might not be enough."

The good news, says Dr. Rutala, is that there are steps you can take today to help prevent GI scope cross-transmission, including the use of disposable sterile GI endoscopes, and such non-endoscope methods to diagnosis or treat disease as capsule endoscopy. Based on outbreak data, Dr. Rutala estimates that you can eliminate about 85% of outbreaks if you curb deficiencies associated with what takes place in the soiled utility room: cleaning, disinfection, automated endoscope reprocessors (AERs), contaminated water and drying.

Nosocomial infections via GI endoscopes are linked to several deficient practices, says Dr. Rutala.

ENDOSCOPE INVENTORY FORMULA
Don't Use Scopes More Than 300 Times Per Year

FULL SERVICE Automated endoscope reprocessors give a thorough channel flushing, continuous leak testing and sometimes more.

Your scope inventory must be big enough to handle your facility's demands, says Erica Natal, BSN, MHA, MBA, director of clinical services at Rockford (Ill.) Gastroenterology Associates. "You cannot rush the [decontamination] process," she says. A sign you don't have enough scopes: Your endoscopists pressure your scope techs to get scopes back in the rotation before they've had enough time to dry.

Here's a simple formula (courtesy of Rockford's scope repair company) to determine your appropriate scope inventory that takes into account scope wear and tear plus turnover time. For each procedure (colon/EGD), divide the number of cases you host by the number of that type of scope you have in inventory. For example, divide the number of colonoscopies by the number of colonoscopes. As a benchmark, the goal is not to use a scope more than 300 times per year. To get an accurate usage number, don't count scopes that aren't used or are rarely used, says Ms. Natal.

Remind physicians that don't know how long it takes to reprocess a scope that any shortcuts taken from the prescribed process to meet a demand put patient safety at risk. "How long does it take to really do it correctly — 12 minutes, 15 minutes, 20 minutes?" asks Donna Nucci, RN, BSN, CIC, an infection preventionist at Yale New Haven (Conn.) Hospital. "One person can only do so much. And is that person competent?"

— Dan O'Connor

• Failing to bedside clean. The pre-clean involves removing debris by wiping the scope's exterior and aspiration of detergent through biopsy channels. Are your techs consistent in their bedside pre-cleaning of scopes, or does this all-important step sometimes fall by the wayside in the rush to turn over a room? "That initial manual clean is every bit as important as what the AER is going to do in terms of high-level disinfection," says Erica Natal, BSN, MHA, MBA, director of clinical services at Rockford (Ill.) Gastroenterology Associates.
• Inadequate cleaning. Did you clean all the channels?
• Inappropriate/ineffective disinfection. This involves time exposure, perfusing all channels, test concentration, ineffective disinfectant and inappropriate disinfectant.
• Failure to follow recommended disinfection practices. A tap water rinse, for example.
• Flaws and complexity in design of endoscopes or AERs. Several manufacturers make automated endoscope reprocessors that high-level disinfect at the push of a button. By connecting a few fittings to the scopes, you've got efficient, thorough channel flushing and continuous leak testing, says Karen Swanson, LPN, CSPM, CFER, the sterile processing manager at Connecticut Children's Medical Center in Hartford, Conn. This equipment also serves as a safeguard against reprocessing errors and the use of damaged scopes, as it will stop its cycle and notify the user if it detects a flaw in the process or the scope.

Some AERs even provide a cleaning cycle that can replace the need for manual brushing. Other options, such as an alcohol flush at the end of the disinfection cycle to facilitate channel drying or a recordkeeping function that tracks scope serial numbers, patient names and cycle details, offer additional levels of effectiveness. Just be sure you know what abilities your equipment is FDA-approved and validated for, and remember that labor-saving doesn't mean labor-eliminating. No AER can make up for a failure to pre-clean the scope at the point of use immediately after a procedure, says Ms. Swanson.

A thankless job
Not only are scopes hard to clean by design. They're also no fun to clean. "Like standing at a sink washing dishes all day," says Ms. Natal of the tedious, backbreaking job that nobody in her facility wants to do. Eight hours in a soiled utility room brushing devices that just brushed up against the body's mucosal surfaces "is a long, hard day," says Ms. Nucci. "I can't imagine myself doing well on my 40th scope at 4 o'clock in the afternoon after doing it since 8 o'clock in the morning."

Reprocessing is best done by a dedicated and certified scope tech, says Ms. Natal, "but no one wants to do that job full-time. The more people you have in and out of the scope reprocessing area, the greater the likelihood of not getting it right and having an infection."