CLOSE INSPECTION Visual inspection alone — even with magnification — is not sufficient to determine the cleanliness of flexible endoscopes.

Are your flexible endoscopes truly clean? It's a question many facility leaders have asked since the deadly "superbug" outbreaks were linked to dirty duodenoscopes. Here are tips gleaned from new AORN recommendations to help ensure your scopes are in tip-top shape for patient use.

1 Record when cleaning begins
Biofilm can start to form in the lumens of endoscopes just a few minutes after use, so it makes sense to record the times the endoscopy ends and cleaning in sterile processing begins. This doesn't need to be a complicated process — it can be as simple as writing the time the endoscopy was completed on a whiteboard in the processing area. Your processing and procedural personnel will need to determine the best way to communicate this information, whether it's through an electronic system or simply passed along while transporting the dirty scope. This may seem like a simple idea, but time really does matter. Each manufacturer has a specified time within which routine processing should be completed. Some manufacturers even require that processing be completed within an hour of the finished procedure. Recording the time the procedure was completed gives personnel the ability to determine how long the endoscope has been awaiting processing, establish priority order and determine if the manufacturer's recommendations are possible.

2 Mechanically clean
Rather than soaking the scope and its accessories after the manual clean, use an automated endoscope reprocessor (AER) to clean scopes (when compatible with the manufacturer's IFUs). Why this change? As we've seen with the recent outbreaks, procedures for manual scope processing may be inadequate or inconsistent. They often vary from one facility to another, and sometimes even within the same facility. Mechanical processors reduce this variability and also reduce the potential for breaches in recommended processing protocols due to human error and noncompliance. The evidence backs the change, too. Using an AER will ensure a scope is exposed to the disinfectant for the necessary length of time. Mechanical processing also thoroughly rinses disinfectants, reducing the potential for patient injury associated with residual chemicals remaining in scopes. While mechanical processing may require an initial capital investment, the consistency associated with it may minimize potential damage and the need to repair pricey scopes.

SAFER STORAGE Instead of the previous recommendation of 5 days, AORN now says you can store scopes for a period of time determined by your facility's experts.

3 Verify cleaning
It's good to inspect your endoscopes, accessories and equipment after cleaning, but visual inspection alone — even with magnification — is not sufficient to determine the cleanliness of complex devices such as flexible endoscopes. Follow manual cleaning with a cleaning verification test at designated intervals. These intervals can vary, depending on your scope inventory and manufacturer IFUs, and could include anything from checking the endoscope after each use to choosing random scopes for daily sampling.

These cleaning verification tests include adenosine triphosphate (ATP) testing or other chemical reagent tests that detect clinically relevant soils such as proteins or carbohydrates. Typically in these tests, a processing team member would swab the scope and either insert the swab into a handheld machine to see if it detects bioburden or ATP, or apply the swab to a solution and look for particular color changes. Though this step does add a cost to your reprocessing practices, periodic verification of cleaning effectiveness may help reduce errors in manual cleaning and improve your overall process.

4 Scope storage
You should store your endoscopes in a drying cabinet. A review of the evidence shows that the optimal storage for flexible endoscopes facilitates drying, which decreases the potential for contamination and provides protection from environmental contaminants.

Drying cabinets include a drying system that circulates HEPA-filtered air throughout the cabinet and forces filtered air that's under pressure through the endoscope channels. The internal and external surfaces of the endoscope are continuously dried this way, suppressing bacterial growth. If you're not using a drying cabinet, you may store flexible endoscopes in a closed cabinet with HEPA-filtered air that provides positive pressure and allows air circulation around the flexible endoscopes.

How long can you safely store scopes before you must reprocess them? Although AORN previously recommended a maximum time of 5 days, we have found that this decision should ultimately be left up to the facilities themselves. This is because evidence regarding maximum safe storage is largely inconclusive. Professional organizations have recommended maximum storage times of anywhere from 3 hours to 1 month, and researchers have recommended storage times ranging from 48 hours to 56 days.

Storage times can be affected by variables unique to the facility, such as the type of endoscopes being processed, the processing effectiveness, the storage conditions, compliance with IFUs, frequency of use and even patient population undergoing treatment with the scopes. Because of that, we recommend you gather a group of stakeholders, such as infection preventionists, processing personnel and endoscopists, to investigate these variables and determine the optimal storage time for your facility. AORN offers an extensive evidence review to assist teams making this decision (osmag.net/RSq7Gk).

5 Stay engaged
Here are a few other updated recommendations your reprocessors should follow.

• Keep scopes clean and dry. Once you've meticulously cleaned your scopes, flush them with instrument air until they're bone dry. Instrument air is defined by the National Fire Protection Agency as a medical gas that is not respired, is filtered to 0.01 micron, is free of liquids and hydrocarbon vapors, and is dry to a dew point of -40 ? F. Clean, filtered air under pressure is necessary for drying lumens and small channels of flexible endoscopes without introducing contaminants into the clean device.
• Implement a maintenance schedule. Assign a multidisciplinary team to work with your scope manufacturer's service representatives to determine preventative maintenance schedules for scopes, mechanical processors and other equipment used for reprocessing. This schedule should align with the equipment's IFUs, but should also take into account factors unique to your facility, such as the types and volume of procedures you perform. This new recommendation helps ensure the scopes are in the best possible condition before use, which may also make them easier to clean.
• Regular education and competency verification. You should be providing education and verifying competency of perioperative, endoscopy and sterile processing personnel on a regular basis, but this is especially important for those individuals who are processing flexible endoscopes. Research shows that when educated and qualified individuals perform processing, variability is minimized and processing becomes more effective.
• Have sufficient inventory. Maintain an inventory of flexible endoscopes and accessories that is sufficient to meet the anticipated demand. You also need to have enough processing personnel to complete the laborious task. To ensure your inventory and number of team members are sufficient, perform an audit focusing on your current use patterns, scheduling and necessary processing times. OSM