Focus on the Fundamentals

Staff Training and Education Instrument Reprocessing and Care Infection Prevention

By: Dan Cook | Editor-in-Chief

Published: 9/13/2021

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Endoscope reprocessing demands following regimented steps every time, not every now and then.


This is an article about endoscope reprocessing. You know what that entails by now. Or at least you should. Scopes are wiped down with an enzymatic cleaner at the bedside as soon as procedures end. They’re placed in a secure container for transport to the reprocessing area, where techs examine them for defects, perform leak tests and conduct a thorough manual cleaning before running them through an automatic endoscope reprocessor. Disinfected scopes are then hung vertically in a drying cabinet designed specifically for that purpose. How hard can it be?

Much more difficult than it appears, apparently, because in April the FDA announced investigations into reports of patient infections related to improperly reprocessed flexible urologic endoscopes. That the FDA spotlighted endoscope care serves as another reminder of the importance of endoscope reprocessing — and how concerns about it being done properly persist. That doesn’t mean the hardworking endoscope reprocessing techs in your facility are doing anything wrong. It also means they might not be doing everything right.

“Reprocessing an endoscope is not simple,” says Linda Spaulding, RN, BC, CIC, CHEC, CHOP, an infection prevention consultant based in Lakewood Ranch, Fla. “The entire process involves multiple steps, with each one as important as the next. When multiple steps are involved, multiple things can go wrong.”

Ms. Spaulding is called into surgical facilities across the country when infection rates rise or problems persist in sterile processing departments. She’s spent enough time in endoscope reprocessing rooms to offer an informed opinion about why endoscope reprocessing issues continue. Her feedback is frank and more than a little concerning. “Some facilities still don’t have a good understanding of the importance of proper reprocessing and storage,” she says.

How could that be? The Association of PeriOperative Registered Nurses has issued guidance on proper endoscope care. The Society of Gastroenterology Nurses and Associates also put out a comprehensive multisociety guideline. Both resources contain comprehensive information and provide detailed breakdowns of the many steps your staff must follow to make sure endoscopes are cleaned, disinfected and stored according to the latest best practices.

The issue isn’t that the essentials of endoscope reprocessing are nonexistent or inaccessible. It’s, as Ms. Spaulding says, that they’re not always followed at sinks and storage cabinets. Messing up a single step, no matter how insignificant it might seem, could lead to a cascade of small errors that combine to become a major issue.

Brush up on the basics

ATTENTION TO DETAIL Staff must complete each aspect of high-level disinfection, even during busy days when several endoscopes are waiting to be reprocessed.  |  Pamela Bevelhymer

Techs don’t have an ability to see residual bacteria and viruses within a intricately designed endoscope — unless they use a borescope to carefully examine deep inside channels after manual cleaning is complete to make sure the surfaces were wiped clean — so they must trust that the reprocessing process ensures scopes are safe to use on another patient.

“Many well-trained endoscope techs work in hospitals and surgery centers,” says Ms. Spaulding, “but there’s always room for improvement.” She notes training and competency assessments must be based on IFUs from the manufacturers of endoscopes, AERs and the chemicals used for high-level disinfection.

Albert R. Knight, MAJ, AN, DNP, APRN, AGCNS-BC, CMSRN, CNOR, perioperative clinical nurse specialist at Landstuhl Regional Medical Center in Germany, believes some reprocessing techs perform steps incorrectly — or skip them altogether — simply because they don’t know any better. 

Dr. Knight says there are few, if any, standardized educational programs based on evidence-based practice that facilities can use to ensure techs are trained on the same techniques, so they’ll reprocess scopes the same way every time.

Training and education on endoscope reprocessing are often subpar, according to Mr. Knight, who conducted a study in 2019 that assessed flexible endoscope reprocessing education and training programs. He found that 80% of the programs failed to cover the importance of visually inspecting endoscopes for damage during the precleaning process and only 40% covered the critically important task of cleaning and brushing the elevator channel on duodenoscopes.

Based on his own observations as a clinical nurse specialist, missteps related to endoscope reprocessing typically involve a lack of precleaning and flushing at the bedside. Busy staff members in high-volume facilities who actually perform the reprocessing steps countless times a day as soiled scopes stack up during days stacked with cases might opt for efficiency over execution. That choice could have dire consequences. “Once biofilm is allowed to form inside scopes, it’s nearly impossible to remove,” says Mr. Knight. That’s why he suggests making sure there are enough techs scheduled to handle turning around the volume of scopes needed based on the number of cases on the schedule. 

Dr. Knight once watched three of his staff members reprocess scopes and saw three slightly different methods. “Small variances in practice can turn into a huge issue,” says Mr. Knight, who has his endoscope reprocessing techs complete a course run by the Certification Board for Sterile Processing and Distribution. “Facility leaders need to use a comprehensive set of standards to train their staff, and make sure they follow each step to the letter.”

There also needs to be consistent oversight of the entire reprocessing process, from bedside to storage. “The steps need to be observed and validated on a consistent basis,” points out Mr. Knight. “But that’s not happening. It’s why we continue to deal with issues related to improper endoscope care.”

Until they start shutting facilities down for improper endoscope care practices, nothing is going to change.
— Albert R. Knight

Additionally, says Mr. Knight, consider the teaching method that will best engage your staff. Older members of your team will most likely prefer hands-on, didactic teaching while younger members might respond best to online teaching modules. “A mix of visual, auditory and tactile learning methods provide a good mix that will connect with most members of your team,” he says.

Ultimate responsibility

Ms. Spaulding has seen facilities install storage cabinets that are designed in a way that doesn’t allow scopes to hang dry. She’s seen members of reprocessing staffs changed more frequently than gloves in a busy OR, and says managers often trust that the rotating cast of characters will do the right thing when the right thing hasn’t been taught.

“These issues often go unnoticed until regulatory or accrediting organizations conduct surveys and notice incorrect procedures are taking place,” says Ms. Spaulding. “In the worst-case scenario, improper endoscope reprocessing is allowed to take place until an outbreak brings the issue to the forefront.”

Says Ms. Spaulding, “Leadership of healthcare organizations or practice settings is accountable to making sure they have sufficient human and material resources on hand to ensure reprocessing is done correctly every time.”

Dr. Knight says contaminated endoscopes are the medical devices most often responsible for healthcare acquired infections and hospital readmissions, and ECRI Institute, a non-profit research firm in Plymouth Meeting, Pa., regularly names the inadequate reprocessing of endoscopes as a top healthcare hazard.

“There isn’t enough accountability,” says Dr. Knight. “Until they start shutting facilities down for improper endoscope care practices, nothing is going to change.” The buck, as always, stops with you. OSM

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