When it comes to scope cleaning, there are some practices that are just plain wrong. And yet, these practices persist — those responsible for scope reprocessing continue to make the same errors when cleaning, disinfecting, and repairing endoscopes. We spoke to manufacturers, repair experts, and educators to find out exactly what not to do.
Top 10 Things Not to Do
“These are the top 10 things people should NOT do when cleaning and repairing scopes,” says Pam Boulet, RN, BSN, CGRN, a clinical specialist at Medivators. They should NOT:
1. Forget to leak-test endoscopes.
2. Submerge the endoscope in water, then apply leak tester.
3. Leak test the endoscope with one water-resistant cap, then prior to manual cleaning, replace with another water-resistant cap.
4. Use the same detergent and/or sponge in the sink/container for more than one scope or worse yet, all day.
5. Pump an arbitrary amount of detergent in the rinse water.
6. Forget to brush the channels.
7. Forget flush the channels.
8. Carry the contaminated endoscope from the procedure room to the reprocessing room not enclosed in a container.
9. Forget to wear personal protection when cleaning endoscopes (i.e., gloves, gowns, face protection)
10. Clean an endoscope if not properly trained.
Rob Purtell, director of business development for Mobile Instrument Service & Repair, says that healthcare workers in charge of cleaning scopes should not forget to put the soak cap on a scope that requires one, before immersing in fluid; they should not leave gross debris inside scope channels, and they should not leave the scope immersed in disinfectant for longer than the recommended time.
Ralph Basile, vice president of Healthmark, emphasizes the need for precleaning as the critical first step. “The longer that proteins and other residual soils are allowed to dry, the more difficult they will be to clean from the scope, inside and out. Rinsing away gross contaminants immediately after use is key to proper reprocessing of scopes.” Basile says that the scope should be cleaned within 30 minutes of use. “Sooner is better,” he adds. “Scopes allowed to sit for more than 30 minutes without reprocessing are at very high risk for developing difficult-to-clean denatured proteins. Denatured protein is the beginning of biofilm and may permanently render a scope impossible to clean.” Basile cautions against assuming that the automatic endoscope reprocessor (AER) replaces the cleaning stage. “Only in the last few months has a piece of equipment come on the market that is meant to replace manual cleaning. But all other automated equipment still requires thorough cleaning prior to placing in the AER,” he says.
“The majority of improper endoscope reprocessing occurs during the manual cleaning stage. Common reprocessing deficiencies are seen in the steps below,” says Eddie Garces, vice president of the Olympus Medical Repair Group.
- Failure to reprocess unique channels (example: elevator wire or auxiliary water channel)
- Not using the proper adapter to reprocess the air/water channels
- Transporting the endoscope without using a closed container or with sharp accessories
2. Leak Testing
- Inefficient examination of the water-resistant cap for damage
- Overlooking pressurization of the scope prior to immersion
- Failure to fully angulate the distal tip during leak test
- Not following the manufacturer’s guidelines for reprocessing a damaged scope
3. Manual Cleaning
- Neglecting to dilute the detergent according to manufacturers’ specifications
- Reuse of disposable brushes and other accessories
- Failure to use manufacturer’s recommended cleaning adapters
- Use of damaged or improperly reprocessed cleaning adapters
- Using a sink or basin of insufficient dimensions
4. High-level Disinfectant
- Inadequately testing the minimum effective concentration of high-level disinfectant according to manufacturer’s instructions (i.e., every cycle)
- Failure to maintain a log of highlevel disinfectant use and endoscope reprocessing
- Oversight in removing all valves and caps when storing the endoscope
- Neglecting to ensure that scopes are hung with all locks in the free position
- Crowded and unsecured scope storage areas
Processing scopes can yield some surprises, according to members of the industry. “I have addressed the strangest things in the field,” says Boulet. “The biggest issue is, how do they reprocess their endoscope with a known leak, before sending out for repair? I was mortified to learn that most people place the contaminated endoscope into the suitcase and just send it off. No red bag, no biohazard sticker, nothing! I always recommend, from an infection control standpoint, that they get with their repair company to address this issue. Boulet offers the following as some of the “craziest” things he has witnessed relating to scope processing
- A tech submerged an endoscope in a sink of water, then applied the leak tester.
- Not leak-testing at all.
- Using the same sink of detergent all day. (“Do they really think anything is left in the detergent for it to work?” Boulet asks.)
- Flushing then brushing the channels.
- Personnel processing the endoscopes in the procedure room when they had a large, beautiful reprocessing room with three sinks available.
- A tech walks out of the procedure room with a contaminated endoscope in a gloved hand, with no gown or face protection on.
- A tech sometimes uses one pump of detergent to a sink of water; another time, five to six pumps are used.
- One water-resistant cap stayed on the leak tester and was used for each scope’s leak test. “After each scope was tested, the cap was removed and replaced with another cap,” Boulet says.
Purtell shares the strangest things done to scopes sent out for repair that his firm has witnessed:
- A distal end was completely crushed, as if it was placed in a vice.
- A scope that was run over by a forklift while in a box at the loading dock — the control body was crushed.
- “We once found a Q-tip left inside a scope from another repair company,” Purtell says.
“One of the most concerning things we see is the exposure of a scope to disinfectants such as glutaraldehyde without thorough cleaning,” says Basile. “Chemicals such as glutaraldehyde (and others) cross-link proteins, creating biofilm that is a source of contamination and a host to microbiological agents.”
Top 10 Recommendations
Boulet’s top 10 recommendations for proper scope cleaning are as follows:
1. Always leak test and ALWAYS inflate endoscope prior to submersion to prevent fluid invasion and cross-contamination.
2. Always dilute detergent according to manufacturer’s directions for use to ensure proper detergent concentration and reaction with debris.
3. Always use fresh detergent and/or sponge for each endoscope being cleaned to ensure reaction with debris and prevent cross-contamination.
4. Always use the same water-resistant cap that passed the leak test procedure, for cleaning the endoscope, to prevent fluid invasion and cross-contamination.
5. Perform bedside cleaning with detergent diluted to manufacturer’s specifications to decrease the potential of biofilm.
6. Always manually clean the endoscope prior to disinfection to remove microbial burden and debris from an endoscope.
7. Brush all accessible channels using a brush compatible with the channel size to ensure debris is being dislodged.
8. After brushing, flush all channels (including special channels) with manufacturer’s cleaning adapters and detergent solution to remove loosened debris.
9. Rinse endoscope and all channels (including special channels) to remove residual debris and detergent.
10. Stay educated on endoscope reprocessing by attending seminars and reading articles.
Alex Vrancich, vice president/general manager at Spectrum Surgical Instruments Corp., offers his top 10 cleaning/good practice recommendations:
1. Clean the scope as soon as possible following the procedure.
2. The AORN recommendations on endoscope cleaning should be required reading for all personnel responsible for cleaning scopes.
3. All cleaning solutions are corrosive and harmful to scope components, so overexposure must be avoided (refer to manufacturers’ instructions).
4. Minimize the number of individuals handling the scope.
5. Minimize the distance between where the scope is used and where the scope is cleaned. If this involves different floors, make sure proper containers are available to transport the scopes (both soiled and clean containers).
6. A fresh, single-use cleaning brush is best.
7. Adequate inventory of scopes will reduce reprocessing pressure and stress and will minimize mistakes and accidents.
8. Leak test, leak test, leak test (before and after use, after processing and before storage)
9. Install a water cap.
10. Educate, train, repeat (especially during staff turnover, vacation, or when using temporary help).
Purtell makes the following recommendations for proper scope cleaning:
1. Always leak test the scope properly.
2. Be sure to completely brush and flush channels.
3. Clean all gross debris from exterior of scope as well as in channels.
4. Always follow the guidelines of both the scope manufacturer as well as the cleaning apparatus manufacturer.
5. Be sure to hang the scope in a well-ventilated area after cleaning/disinfecting.
6. Clean all the valves properly.
Basile offers the following tips:
1. Thoroughly pre-clean at bedside.
2. Be sure all scopes begin the reprocessing process within 30 minutes of use.
3. If a scope goes longer than 30 minutes without reprocessing, develop a special set of procedures for more thoroughly cleaning these scopes, and adopt a method for verifying their proper cleaning.
4. Clean all channels of the scope, not just the biopsy and suction channels. Other channels, including the alternate water channel, can be exposed to contaminants, even if they are not used during a procedure.
5. Adopt a feedback loop to ensure reprocessing. There are commercially available tests and methods that can be employed to periodically check scopes to see if they have been thoroughly cleaned.
6. Be sure to review and have at ready access the reprocessing instructions from the scope manufacturer, the detergent manufacturer and the AER manufacturer.
7. Each member of the team must be thoroughly trained and their competency tested on each and every piece of equipment. This should be done at least once per year per employee and every time a new piece of equipment (scope, AER, etc.) is brought in for use.
8. If the facility does not have one, consider purchase of an AER.
9. If a full-blown AER is too expensive or not practical, consider purchase of one of the mechanical flushing aids 10. Develop a partnership with your suppliers — of scopes, of scope repair, of detergent and of cleaning equipment.
“There are particular cleaning steps that are more likely to be skipped in scope cleaning or ‘glossed over’ and done improperly,” says Garces. He offers a few tips for avoiding scope damage that can lead to fluid invasion: Handling
- Protect the scope at all times.
- Avoid coiling insertion tubes too tightly.
- Avoid stacking scopes with accessories or other scopes during transport.
- Use care when handling scopes around sharp objects and metal surfaces.
- Check compatibility and working condition.
- Examine condition and size-compatibility of accessories to avoid damaging channels.
- Inspect and test scopes prior to each procedure to catch damage early on.
- Regularly check caps, pistons and visible seals for wear and tear to ensure the scope is watertight.
- Follow original equipment manufacturer’s (OEM’s) operating instructions.
- Take care when picking up the instrument or putting it down.
- Avoid exerting too much force on buttons, switches, angulation cables or the control grip during use to help prevent punctures, cracks and buckling.
- Inspect each EndoTherapy device before inserting it into the channel. Stop when you encounter a restriction, and don’t attempt to advance the device while the scope is angulated.
- Make sure the device is in the field of view before opening or engaging; good communication between nurse and physician is critical.
- Train, train, train.
- Avoid stacking a scope on its own distal tip.
- Do not reprocess scopes together unless using a reprocessing machine specifically designed for reprocessing two scopes in a single basin.
- Check sinks, drains and countertops for sharp edges; remove unnecessary objects nearby.
- Ensure reprocessing staff has adequate reprocessing time. Don’t rush.
- Always follow all four reprocessing steps:
1. Bedside Cleaning
Check integrity of the water-resistant cap and make sure it is dry. Put the cap on before cleaning at bedside. Clean at bedside before bioburden hardens to avoid the need for aggressive cleaning later.
2. Leak Testing Leak-test before manual cleaning.
Use a sink that is large enough to avoid crimping the instrument. Post the appropriate OEM leak testing instructions.
3. Manual Cleaning
Avoid undue chemical damage by adhering to OEM instructions for reprocessing time/temperature/concentrations using recommended detergents and sterilants. Follow the detergent manufacturer’s instructions to ensure the proper detergent concentrations. Use appropriate cleaning brushes that are in good working condition.
4. High-Level Disinfection (HLD) or Sterilization
Follow the scope manufacturer’s approved protocols for high-level disinfection or sterilization. Follow the manufacturer’s instructions for use of AERs or sterilants. Use only endoscope-compatible liquid chemical germicides recommended by the scope manufacturer that have been tested for proper potencies.
- Protect scopes when they aren’t in use.
- Store scopes in a clean, ventilated and uncluttered cabinet (not in the carrying case).
- Hang scopes vertically with valves and caps removed and with locks in the “free” position.
- Preventive maintenance Fix minor damage quickly before it escalates.
- Regularly check endoscopic equipment and accessories for wear.
- Ensure scopes are repaired to OEM specifications.
- Retire outdated equipment and keep active scope inventory levels on par with patient volumes.
- Keep appropriate staff trained on handling, operating and reprocessing protocols.
Consequences of Improper Scope Cleaning
By Eddie Garces
Cleaning is the most critical reprocessing step, removing more than 99 percent of the bio-burden from the endoscope. Failure to properly clean endoscopes has considerable consequences for both the patient and the healthcare provider. First and foremost, inadequate endoscope cleaning jeopardizes patient safety. Although pathogen transmission in endoscopy is rare, documented cases of pathogen transmission have been invariably linked to breaches in reprocessing, with the majority being associated with a failure to properly clean the endoscope according to manufacturer’s instructions.
Second, healthcare facilities must expend considerable resources to investigate cases of both patient infection and pseudo-infection related to inadequate endoscope cleaning. In addition, the identification of improper endoscope cleaning as part of an infection control investigation may lead to patient notification and testing — a consequence of which may be multiple lawsuits and immeasurable damage to the healthcare provider’s reputation. And finally, improper reprocessing may result in endoscope damage and higher repair costs for the facility. Overall, failure to properly clean endoscopes produces a myriad of avoidable consequences that drain resources from effective healthcare delivery and improving patient outcomes.
Scopes should be checked for proper functionality/ potential maintenance needs, as there are obvious signs that a scope is not working properly and should be evaluated.
Functionality and visual inspections of the endoscope should be checked before every procedure. An inspection of the functional aspects of the scope prior to each procedure will help to ensure that the scope is ready to be safely used. Additionally, proactive inspection of the condition of the instrument may significantly reduce the frequency and extent of repairs. Some indications that a scope may be in need of repair include signs of physical damage or poor functioning like sharp edges on the distal tip, cracks/peeling on the insertion tube, poor air/water flow, change in image quality, and reduced angulation. Proper care, handling and reprocessing in conjunction with the original equipment manufacturer’s provided instructions — such as leak testing after every procedure — will maximize the up-time of endoscopes.
It is important to repair scope flaws right away, as waiting may exacerbate costs and safety issues. At a minimum, a damaged scope will cause the cancellation of procedures and the delay of patient treatment. Using a damaged scope with reduced functionality may cause increased procedure time, decreased patient comfort, and require the use of more medication. More serious potential hazards can include the failure of an endoscope during a procedure, compromising patient safety, and increasing liabilities. Most types of endoscope damage, if left unattended, will lead to elevated repair costs. Fluid invasion is the best example.
Clinicians should maintain scopes in the best possible condition. There’s a misconception that scopes will break and leak, regardless of how much care is taken with them. However, a majority of the repairs that we see are preventable. There are many things that can be done to substantially reduce the chance that a scope will require repair. Scopes need to be leak tested after every procedure, and the condition of the water-resistant cap must be checked with every use. Immediate bedside cleaning reduces the possibility of damage such as clogged nozzles. Another important factor is proper endoscope handling. In general, be conscious of any surface with which a scope comes in contact, as it can be a potential source of insertion tube punctures and damage.