GOOD START Proper manual cleaning is a key initial step of flexible endoscope reprocessing.

Flexible endoscopes are expensive to buy and costly to maintain — general diagnostic scopes run $25,000 to $35,000 and repairs can range from $500 to $10,000 — but proper care and handling increase their usable life. Problem is, there's a lot of opportunity for lapses in protocol during endoscope reprocessing that can not only harm scopes, but also potentially cross-contaminate patients. Unless you're standing vigil in your decontamination room, there's no way to know scopes are reprocessed properly each time they pass through. If that uncertainty keeps you up at night — and it probably should — follow these 7 steps to all but guarantee scopes are handled correctly and readied for safe patient care.

1. Certify and educate. The Certification Board for Sterile Processing and Distribution (sterileprocessing.org) offers GI scope certification for qualified members of your staff who are responsible for cleaning and disinfecting flexible endoscopes. Support anyone who expresses interest in the certification exam and do your best to fund their efforts. It makes sense to have at least 1 staff member in your reprocessing room gain certification, but I suggest you have a nurse and tech seek certification. The certified team, with your oversight, would be responsible for owning the reprocessing process. They'd champion the cause, declare reprocessing staff members competent to do their jobs, facilitate product demonstrations when you add new scopes, and help review and update policies and protocols.

2. Handle and clean properly. Initial bedside cleaning ensures scopes are flushed with enzymatic cleaner as close to the time of use as possible. Contain scopes in a closed system during transport to the decontamination room to avoid transmission risk to staff and patients, and to protect the delicate scopes.

Perform leak testing, an important step of scope reprocessing, to check for small holes or issues that jeopardize scope integrity. Next, meticulously clean the working channel, the insertion tube and the umbilical section that attaches to the image processor with a brush that's the correct size and length, according to the scope manufacturer's directions for use. Flush the scope and channels with enzymatic solution and water, and empty the scope of excess water before placing it in the automatic endoscope reprocessor (AER). Some AERs are FDA-approved to perform an automatic cleaning cycle that's said to eliminate the need for manual cleaning, but guidelines issued by the Society of Gastroenterology Nurses and Associates state that we should still perform manual cleaning.

3. Make it automatic. It's reassuring to know that AERs have mechanisms to ensure each cycle of reprocessing is completed. Some AERs automate leak testing. That's nice, because manual testing can be a subjective process that could result in missed leaks. Some AERs also stop cycles if scopes aren't connected correctly, the proper pressure gradient isn't reached, exposure to the high-level disinfectant is jeopardized or blockage occurs in one of the channels.

AERs that prevent the next step of reprocessing if some aspect of the cycle isn't working properly can stop improperly disinfected scopes from being used unknowingly. Relying on the advanced design of these units can help ensure scopes will be disinfected to the highest level. Plus, AERs with multiple bays that can run independently may allow for improved reprocessing efficiency.

4. Store properly. Flush scope channels with 70% to 90% ethyl or isopropyl alcohol followed by forced air. This final step before hanging in storage helps reduce the risk of microorganisms remaining in a moist channel.

Current research focuses on how long scopes can be stored before redisinfection for reuse is necessary. There is limited clinical evidence to support redisinfecting scopes after they're hung, and current guidelines don't provide a clear answer. The Association for Professionals in Infection Control and Epidemiology (APIC) suggests 7 days of storage as the acceptable cutoff. AORN says 5 days. A multi-society guideline on reprocessing flexible endoscopes states that it may be advisable to redisinfect scopes stored for 7 to 14 days if a subsequent patient is immunosuppressed or the scope could enter the retroperitoneal space or biliary tree during an endoscopic retrograde cholangiopancreatography (ERCP).

Those are the loose recommendations. So what do you do as a manager? The evidence may eventually show that it's not necessary to determine a specific hang life, but because societal guidelines do touch on the topic, it makes sense to develop a policy. Work with your infection control team and medical staff to determine what, if any, hang life you will use, and be sure it's realistic and sustainable for your unit's operations. To help your staff track the days between decontamination and reuse, note the expiration date on each scope (tinyurl.com/lfmsz2s) so members of your reprocessing team don't have to count forward when reading a tagged scope in storage.

SAFETY CHECK Many automatic endoscope reprocessors abort cycles if scopes aren't connected properly.

5. Audit and teach. Partner with your infection preventionist to keep close tabs on the work being done in the reprocessing room. Put her in charge of auditing the process. She'll likely catch the little errors that could amount to major issues. Initially, have her conduct random, weekly audits of the reprocessing process. She should review reprocessing logs and conduct real-time teaching. Continue the weekly auditing for several months before eventually scaling them back to biweekly and, finally, monthly. She should never let more than month lapse before auditing the reprocessing room. Your techs might not like the surprise visits, but they'll quickly realize that their actions are under close scrutiny and that they need to raise their level of performance. In some ways, it helps them become better at their jobs. Instead of rote reprocessing, they have to explain the rationale behind each step, which signals true understanding.

6. Have a presence. Visit your reprocessing room every day and engage the team. You don't have to perform a full audit, but the regular face time will keep staff on task and you aware of what's really happening in the reprocessing area. Make sure staff have needed resources. I've seen techs use the wrong-sized brush because they ran out of the correct size. Regular observations will help ensure that's never an issue.

7. Rotate staff. What happens if one of your regular techs is absent, leaving the reprocessing room short-staffed? Rotate endoscopy techs through the cleaning room so they reprocess scopes about once every month. Doing so will keep their skills fresh, so reprocessing quality won't suffer if regular techs are absent.