By Barbara Zuccala, MSN, RN, CGRN
Complacency in the high-level disinfection (HLD) and manual pre-cleaning of endoscopes is never an option. In order to ensure competency, an institutional quality program with written policies and procedures for endoscope processing must be established and strictly followed. These policies should be based on the Society of Gastrointestinal Nurses and Associates (SGNA) and the American Society of Gastrointestinal Endoscopists (ASGE) guidelines for the reprocessing of endoscopes.
Competency in all areas of infection control should be demonstrated by nurses and technicians in the GI unit and include standard precautions, reprocessing procedures for equipment and accessories, and the safe handling of chemicals, spill containment and waste management.
The endo technicians who are responsible for the high-level disinfection (HLD) of endoscopes must be permanent staff members; per diem or float staff should not be trained and responsible for endoscope reprocessing. Competency and proficiency in endoscope reprocessing cannot be maintained unless routinely performed. This should be the responsibility of permanent staff who reprocess endoscopes and accessories on a regular basis. All employees responsible for the cleaning and reprocessing of endoscopes need to understand the importance of this job.
Staff should be properly trained according to these guidelines and must prove the process. These competencies need to be demonstrated and assessed regularly—at once or twice a year. Since there are several different models of endoscopes, it is imperative that the technicians are knowledgeable and proficient in the cleaning and reprocessing of all types of endoscopes used in their unit.
For instance, ERCP duodenoscopes and linear EUS scopes have additional channels/elevators that must be cleaned properly to prevent the transmission of infection. These endoscopes are essentially difficult to reprocess, but strict adherence to the manufacturer’s reprocessing instructions will minimize the risk of infection. Deviations from the manufacturer’s instructions for reprocessing may contribute to contamination and the spread of infection. All scopes must be meticulously pre-cleaned by hand, with special attention given to each channel—even when staff uses an automated endoscope reprocessor.
Several evaluation methods can be used to assess for competency in the HLD of endoscopes and accessories, including demonstration and direct observation, oral (verbalizing knowledge) and written testing, and documentation review.
The technicians should be observed performing all of the required steps in the manual cleaning and reprocessing of endoscopes. The trainer also should ensure that the technicians understand the proper testing of the minimum effective concentration (MEC) of the high-level disinfectant used in the process. Staff must also know how to properly use personal protective equipment. The trainer should ask questions while observing—about the steps in reprocessing, leak testing, MEC of chemical used in reprocessing, quality control of the chemical used in scope reprocessing, and the handling of spills.
Verbalizing knowledge is another method used in the evaluation process. Techs should be able to explain or discuss of the following: location of the Material Safety Data Sheet (MSDS) for the chemicals used in your facility; the handling of high level disinfectants used in the facility; spill containment; quality control testing of high-level disinfectant used; and the proper storage/expiration and use of the HLD test strips.
The trainer should periodically review the logs of MEC, ensuring that MEC is being performed and documented correctly. An audit of the decontamination room should be done at least twice a year to ensure that expiration dates are on all opened containers and that there are no expired products; automatic endoscope reprocessors and adapters are working properly; and sinks are working properly. The trainer also should check for plumbing leaks, proper air exchanges and a clean and orderly room, as well as ensure that spill containment products are available, and the MSDS book and HLD policy are available and up to date.
To ensure compliance in all areas of HLD process, there should be frequent monitoring by the trainer or educator, and involvement by leadership helps demonstrate the importance and value of the work that the assigned endo technicians perform daily. The nursing staff and managers should also be competent in the reprocessing of scopes, otherwise they will not be able to recognize when errors or breaches in protocol may occur.
Certification for the technicians who are responsible for the decontamination of endoscopes is now mandatory in some states. Encouraging certification provides the technicians with the knowledge and confidence to do this work proficiently. It also ensures management that the technicians have the skills and knowledge to do this job properly and in accordance with the guidelines.
As trainers and educators we must know, train and enforce the standard. Time pressure should never compromise the process. The technicians must know that they have the support of management—so they do not succumb to pressure from physicians to reprocess scopes rapidly to keep up with the demands of the unit’s scheduled cases. If any step in the cleaning and reprocessing of scopes is not performed properly or compromised it must be reported. Encourage staff, “If you see something, say something." The safety of our patients should never be at risk.
Endoscopes reprocessed appropriately and in accordance with reprocessing and infection control guidelines pose virtually no risk of transmission of patient-borne or environmental microorganisms. Every reported case of hospital acquired infection associated with a contaminated GI scope has been linked to a breach in at least one of the requisite reprocessing steps. We just need to follow directions to ensure patient safety. (Thornbill, 2012)
Barbara Zuccala, MSN, RN, CGRN, is an endoscopy clinical specialist at the Valley Hospital in Ridgewood, N.J.
Reference: Thornhill G. A Risky Undertaking: Manual Cleaning of Flexible Endoscopes. Healthcare Purchasing News, 40-42. 2012.