On the Road with Dirty Scopes

Follow the IFU to the letter, as there are minor variations from vendor to vendor. Also follow the IFUs for your cleaning solutions and processing equipment. And safely dispose of any single-use accessories according to your facility's policy; same goes for environmental cleaning.

The pre-treatment process often gets short shrift. "These steps are easier to be missed, or performed incompletely, because of the desire to move faster, and thinking that the steps that happen once the endoscope is in the reprocessing room will catch what was missed prior," warns Jeanine Penberthy, MSN, RN, CGRN, of University of Washington Medical Center, who serves on the Society of Gastroenterology Nurses and Associates (SGNA) board of directors.

2. Contain. Once you perform pre-treatment, coil the dirty scope in naturally large loops and place it in a dedicated, secure, leak-proof, puncture-resistant, closed container clearly marked with a biohazard label. The container should be large enough that the scope doesn't need to be looped too tightly, which can cause damage. That's a major consideration, as you want to extend the service lives of these fragile, costly devices while keeping them safe for reuse. To prevent cross-contamination, don't combine multiple scopes in the same container, and don't place any related surgical instruments in the container either, as they could puncture the scope.

Absolutely do not use drapes, pillow cases or bags to move dirty scopes. Not only will using a secure container prevent any spillage, but it will protect your staff and patients from possible infection. If you do use bags that are designed for containing soiled endoscopes, be sure to place them in a secure rigid container to protect the endoscope.

It's widely accepted that the length of time between withdrawal, pre-treatment at point of use, and complete decontamination should be no longer than 1 hour. If it sits any longer, you run the risk of forming a biofilm, a tightly bound network of microorganisms that proliferates and creates a barrier that's difficult to remove. If that happens inside an endoscope — say, in the long narrow channel where you can't see things without specialty equipment like a borescope — it becomes very hard to remove, a lot like a casserole dish with burnt cheese that you forgot to soak. To combat that possibility, keep dirty endoscopes and accessories wet or damp using an approved agent — though not submerged in liquid — in the container. This helps dilute and soften contaminants and facilitates an easier cleaning process downstream.

3. Transport to decontamination room. Now that your scope's packed up and ready to go, you need to get it to the decontamination area as quickly and safely as possible. All kinds of mishaps can occur on the way from the exam room to the reprocessing area. Interruptions happen, and hallways can be busy, cramped places. So, as an added measure, you should employ a cart of some type to transport the container. Not only does this reduce the possibility of a staff member tripping, or bumping into something or someone, and dropping the container, but it also helps them avoid possible physical injury and strain from carrying the container.

The container and cart should be constructed of material that can easily and repeatedly be cleaned with germicides or thermal cleaning using EPA-registered, hospital-grade disinfectants. Everything else that's on the cart should receive the same cleaning, too. Cleaning can be performed manually or mechanically, depending on your center's resources and equipment.

It's imperative to use separate carts and containers for dirty scopes and clean scopes, each of which should be easily distinguishable from the other using clearly marked visual cues. Clean scopes also should be marked as such, so dirty scopes are never accidentally mistaken for clean.

4. Handoff. So your staffer has navigated the obstacle course with the cart and has reached the decontamination room. It's not enough to just drop it off there, however. Remember that 1-hour rule? Unless there's a really good handoff protocol from the point-of-use transport person to the decontamination person, the latter may not know when the scope was withdrawn from the patient.

"This communication is an area every facility can improve upon," says Dr. Kyle. "No one's doing this as well as it should be done, and in a fast-paced medical setting, it's really easy to lose track of time."

You need a protocol that's standardized and makes this vital communication very clear and consistent. You might choose to do it in writing, using labels on the scope or container, or you might prefer to do a warm handoff with an oral report. Just come up with a process that's standardized, effective, and reliable — and works best for your center.

5. Transport of cleaned scopes. OK, now you have completed processing your endoscope. The journey back to storage or the next procedure can be equally perilous, so you must tread carefully here as well to prevent recontamination of the scope.

If you can sterilize the scope, it really simplifies the transport of the item, says Dr. Kyle, because it will be packaged with a sterile barrier system that protects it from contamination. For all critical applications like surgeries where the endoscope enters normally sterile tissue, the scope absolutely needs to be sterilized, not just HLDed.

HLD is OK for semi-critical procedures like screening colonoscopy, where the scope is only coming into contact with intact skin and mucus membranes and not entering normally sterile tissue. No matter if the scope is going to be used immediately or stored, it needs to be completely dried in the processing area using instrument air — filtered air that's monitored and regulated.

If you use HLD, and the scope is going to be used immediately, you must place the scope in a clean container by a person who's performed hand hygiene and is wearing gloves to be transported to the point of use. If you're not going to use the scope immediately, store the clean scope in an endoscope storage cabinet that is a drying cabinet. That's the best way to protect endoscopes while in storage from contamination. Such a cabinet will "allow each scope to hang freely without touching other scopes, and it connects to filtered air that's forced through the scope's channels continuously," says Dr. Kyle.

There's no real consensus on how long HLDed scopes can be safely stored before use. "Because of this lack of consensus, some facilities choose to always reprocess stored scopes right before they're used again, just to be on the safe side," says Dr. Kyle. That might not be feasible for some locations, but it's a good practice if you can do it.

6. Define a policy that's explicit and inclusive. It truly takes a village to ensure proper handling and transport of scopes in your facility. You should assemble an interdisciplinary team that includes endoscopists, processing staff, perioperative and endoscopy registered nurses, infection preventionists and any other personnel involved in the use and processing of endoscopes to collectively develop an explicit, end-to-end policy.

Dr. Kyle suggests you ask these tough questions about transport and handling of scopes from the point of use to decontamination when you're putting that policy together:

• Is point-of-use treatment happening correctly?
• Does the team have the tools they need to perform each step correctly?
• What is your communication process when transporting and handling soiled endoscopes?
• Does your team know when they need to use "delayed processing" procedures when too much time has passed between scope use and cleaning; how do they know how much time has elapsed?
• How confident is your team that the scopes are processed effectively; how do they know?
• Does the physician know how his handling of the endoscope affects processing, for example, the use of simethicone?
• What are the storage conditions like; does the storage cabinet have HEPA-filtered air, but it's not forced through the channels?
• Where are the cabinets located, and how often are they opened, and by whom, to retrieve or place items?
• Are personnel who handle endoscopes performing hand hygiene correctly every time?

Address every loose end, suspicion and problem, create a policy, make sure everyone involved can actually perform their assignments given all their other tasks, and tie it into your overall infection control protocol.