Endoscope Cleaning: What Infection Preventionists Should Know

January 7, 2021
Frank Diamond

Linda Spaulding RN, BC, CIC, CHEC, CHOP: “Infection preventionists need to learn how to clean an endoscope, or at least observe the cleaning…. Infection preventionists need to make rounds, they need to talk to the person processing.”

In the life-or-death battle that infection preventionists and other healthcare professionals have been engaged in with coronavirus disease 2019 (COVID-19) this last year, some rudimentary infection control practices may have been sidelined if for no other reason than elective procedures have been sidelined. That concerns infection control expert Linda Spaulding, RN, BC, CIC, CHEC, CHOP. Spaulding, a member of Infection Control Today®’s Editorial Advisory Board, worries that in the post-COVID healthcare setting, the proper cleaning of endoscopes might not happen—at least not right away. “Those scopes have been sitting there for how many months now?” Spaulding tells ICT®. “We have to get back together and put together better programs and make sure we’re safe from there on.” Spaulding believes that infection control needs to function as a buddy system. “Whether it’s cleaning scopes, decontaminating and sterilizing surgical instruments, or putting on PPE. Somehow, in my opinion, we have to start having buddies in the hospitals, in clinics, in long-term care. We keep an eye on each other and remind each other about infection prevention practices.” Spaulding believes healthcare needs to be looked at in a “totally different light” post-COVID because “we can fix a lot of things before our next pandemic.”

Infection Control Today®: So what are your thoughts about the cleaning of endoscopes?

Linda Spaulding RN, BC, CIC, CHEC, CHOP: OK. Well, you know, for the past few podcasts, we talked a lot about COVID. I think now it’s time to try to get back to other things, post-COVID, or in conjunction with COVID. And prior to COVID happening, we had been working a lot to prevent infections being transmitted from endoscopes. And what I mean by that is the endoscopes are used on the internal parts. Inserted internally on multiple patients with the same endoscope. Processing these scopes in between each patient is extremely important so you don’t take bacteria from one patient and accidentally insert it into the next patient and cause an infection.

Over the years, we’ve had many outbreaks of infections related to endoscopes not being processed correctly. In January 2017, the CDC’s (US Centers for Disease Control and Prevention) HICPAC (Healthcare Infection Control Practices Advisory Committee) group; we had worked on new endoscope guidelines for probably a couple years before they were published. And they were published January 25, 2017. And what we found is that we got a little bit of traction, but not as much traction as we would hope to see. When people are hired into the endoscopy department, sometimes they do the endoscopy and assist the physician as well as clean the scopes. If you’re having a really busy day, the scope might not get cleaned as good as it should. And if it was cleaned properly, we wouldn’t have had clusters of infections related to them. So, one of the things that I think is essential for us to get out to people post-COVID—to start thinking about these things, again, trying to get back into some normalcy—is people in these departments and managers of these departments need to go on the HICPAC website. And they need to download this document that I have right here with some of my notes on. It’s called “Essential Elements of Reprocessing Program for Flexible Endoscopes—Recommendations of the Healthcare Infection Control Practices Advisory Committee.” This is an incredible tool that I wish I would have had earlier in my infection control career. Not only does it give you good information related to scopes, and processing, but if you don’t have a strong program setup, it gives you everything to put that program in place. It gives you a policy format. It gives you audit tools. It gives you a competency verification tool, so you can make sure your people are competent. It gives you an inventory repair and maintenance log so you can log every single time a scope breaks and when it goes out. You can identify if you have a problem scope because it keeps going out for repair. And it also gives you a gap analysis tool and an RCA template. Now, some people may not know what a gap analysis tool is. But this is the actual tool that’s on the website. And it goes through everything you need to look at to make sure you have a good strong program in place. As you go through this, if you can answer “yes” to all of this, then you can be comfortable, you probably have a pretty good program in place. If not, it gives you the chance to say “OK, we don’t have this in place” or “We’re weak in this area.” And then that’s what you focus in on improving. I’ve gone in to do accreditation for hospitals where they didn’t even track their scopes. They didn’t know what scope was used on what patient or they didn’t know that a particular scope kept breaking down. And that’s the same one they kept sending out. Because their tracking programs just aren’t there. What we did with the HICPAC committee is we put every single document together that you need to be able to have a strong, effective safe program. And CDC has their HICPAC meetings on campus in Atlanta. And we have general public people that are allowed to make comments at the end of the meeting. And I was a liaison on the HICPAC committee for five years. At the end when the general public would get up and ask questions, we would have family members that would come to the mic and tell us how we need to concentrate on endoscopes because their husband, their father, their daughter, had died because of an infection that was contracted from an endoscope. We want to think that all hospitals do everything correct. They all have best practice at heart. Nobody wants to do something wrong. But some just don’t have the tools to know what they’re supposed to be doing. They were hired, they were shown how to clean the scope. And then they’re out of orientation. If they were taught wrong, they’re cleaning the scopes wrong. There has to be verification and validation of everything.

ICT®: Who actually does the physical cleaning of the scopes? Is this something that infection preventionists oversee? Or do they clean the scopes themselves?

Spaulding: No, usually infection preventionists don’t have anything to do with it. If there’s an outbreak, then infection preventionists will be all over it. But essentially, you could be hired by a hospital tomorrow. You can be told you’re going to be the endoscopy scope cleaner, or tech. They’ll bring you in, they will work with you, show you. Put you through training on how to clean the scope. Show you where everything is. And then you’re the endoscopy cleaning person. In some hospitals, it might be a nurse, because the nurse is helping the physician do the scope, then the nurse is cleaning the scope afterwards, getting it ready to use on the next patient and the next doctor who is coming in. You could see how shortcuts could be taken. And so, anybody can be trained to clean the scope. It’s just how well are they trained? And is the person training them really doing it correctly? And usually when we have outbreaks in these areas, we find that somebody was trained wrong. Or somebody says, “Yes, I follow all the steps that’s on this poster.” And then when you observe them, you find out they missed one or two steps. Those one or two steps are critical. We were talking about central line infections in another talk. I think I brought it up. It’s the same thing. If somebody’s not visually verifying and validating that the person is still doing it right, even if that person has been there 25 years, then things can go wrong, and you can end up with infections. You have some people that have been there 25 years. All they’ve done is scope cleaning. “Of course, I’m really good at it. I’ve been doing it for 25 years.” Yet we still find shortcuts. Because somewhere in their career, they decided to take a shortcut because they had to turn the scope over really fast. And then it’s like, “Oh, well, it worked that time. I’ll just keep doing it this way, because it’s quicker.” And nobody’s going to know that there’s an outbreak from endoscopes until enough physicians identify for themselves that, “Oh, I have a patient that got infected.” Then they hear from another doc. “You know, I have a patient that got infected after an endoscope.” And then they hear the third doc. And then the docs kind of put it together. “Wait a minute, there are three patients that had endoscopes here.” But if each physician is only seeing one at a time, nobody’s putting it all together that there’s a problem because the likelihood of one physician—unless he’s the only one that does the endoscopes—being able to identify an infection and [know how many people got infected is unlikely.] And if the docs aren’t talking and sharing that information, then nobody really knows until you have a whole lot of people infected. We’ve had CRE (carbapenem-resistant Enterobacteriaceae) transmitted by endoscopes. There has been C. diff transmitted to multiple patients through endoscopes. Our goal would be: “Wouldn’t it be great if we had disposable endoscopes?” And we were talking about that prior to COVID. And then all that stopped. So, we have to get back to basics, post-COVID, and start looking at our programs again. Because most likely, during COVID, people got out of the routine of cleaning endoscopes because we weren’t doing them because they were elective. And those scopes have been sitting there for how many months now? We have to get back together and put together better programs and make sure we’re safe from there on.

ICT®: And finally, where do infection preventionists fit in this? Should they insist on trying to have more oversight on the endoscope cleaning process? Or will people be wary of that?

Spaulding: No. Infection preventionists need to learn how to clean an endoscope, or at least observe the cleaning. Every company that puts endoscopes out have really good posters on how to clean each part of the endoscope. Infection preventionists need to make rounds, they need to talk to the person processing. They need to watch the person processing and making sure there are no steps missed. Maybe I’m doing it and I missed step number three, and I didn’t even notice it. So, I go on to step four or five or six. If I have a buddy standing next to me, they can say, “Oh, wait a minute. You missed this one.” Infection control has got to become a buddy system. Whether it’s cleaning scopes, decontaminating and sterilizing surgical instruments, or putting on PPE. Somehow, in my opinion, we have to start having buddies in the hospitals, in clinics, in long-term care. We keep an eye on each other and remind each other about infection prevention practices. Even hand washing. See a physician or nurse or an aide or housekeeper come out of the room and they forgot to wash their hands. Everybody needs to say, “Oh, you missed a handwashing opportunity.” I tell my clients, during orientation you tell them that if a person walks out of the room and hasn’t washed their hands, that they will be possibly seen and another co-worker will say, “Hey, you missed an opportunity to wash your hands.” And the only thing you can respond is “Oh, thanks for letting me know” It takes away the meanness that can come out. “Don’t tell me what to do.” Or “I’m always being picked on.” Hospitals should let people know at the time of orientation that this is the culture we have at this hospital. If you don’t have your PPE on right, somebody may come to you and say, “Hey, let me help you put that on because it’s not on correctly.” We’ll save healthcare workers lives and will prevent infections in our patients. I think we just need to look at healthcare in a totally different light post-COVID than we did pre-COVID. Because we can fix a lot of things before our next pandemic.