Endoscope Cleaning: What Infection Preventionists Should Know

In the life-or-death battle that infection preventionists and other health care professionals have been engaged in with coronavirus disease 2019 (COVID-19) this past year, some rudimentary infection control practices may have been sidelined due to elective procedures being 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-19 health care setting, proper cleaning of endoscopes might not happen, at least not right away. Spaulding says she believes that “we have to start having buddies in the hospitals, in clinics, in long-term care. We [need to] keep an eye on each other and remind each other about infection prevention practices.” Health care should be looked at in a completely different manner after COVID-19, she says, so “we can fix a lot of things before our next pandemic.”

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

Linda Spaulding, RN, BC, CIC, CHEC, CHOP: We’ve talked a lot about COVID-19. I think now it’s time to try to get back to other things, post–COVID-19 or in conjunction with [it]. [Previously], we had been working a lot to prevent infections being transmitted from endoscopes. What I mean by that is that the endoscopes are used on [a patient’s] internal parts, [and] inserted…in multiple patients. Processing these scopes in between each patient is extremely important so you don’t take bacteria from 1 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. …The CDC’s [Centers for Disease Control and Prevention] HICPAC [Healthcare Infection Control Practices Advisory Committee]…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 as we had…hoped….

When people are hired in 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 scopes might not get cleaned as [well] as they should. If [they had been] cleaned properly, we wouldn’t have clusters of infections related to them. So, one of the things that is essential for us to get out to people post–COVID-19—to start thinking about these things again, trying to get back into some normalcy—is that people…and managers of these departments need to go on the HICPAC website. They need to download this document that I have right here…called “Essential Elements of a Reprocessing Program for Flexible Endoscopes—Recommendations of the Healthcare Infection Control Practices Advisory Committee.”1 This is an incredible tool that I wish I [had] 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 [and] audit tools. It gives you a competency verification tool so you can make sure your people are competent, [and]…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 [root cause analysis] 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 that’s what you focus 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…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. …HICPAC…has put every single document together you need to…have a strong, effective, and safe program. CDC has their HICPAC meetings on campus in Atlanta, and the general public are allowed to make comments at the end of the meeting. I was a liaison on HICPAC for 5 years. At the end, when [people] would get up and ask questions, we would have family members…come to the mic and tell us how we needed to concentrate on endoscopes because their husband, their father, their daughter had died because of an infection contracted from an endoscope. We want to think that all hospitals do everything correct, they all have best practices at heart. Nobody wants to do something wrong, but some [people] 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 physically cleans the scopes? Is this something 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 and… told you’re going to be the endoscopy scope cleaner or tech. They’ll bring you in, …work with 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 afterward, getting it ready to use on the next patient and for the next doctor who is coming in. You can see how shortcuts could be taken. So anybody can be trained to clean the scope. But how well are they trained, and is the person training them really doing it correctly?

Usually, when we have outbreaks in these areas, we find that somebody was trained wrong. Or somebody says, “Yes, I follow all the steps on this poster.” And then when you observe them, you find out they missed 1 or 2 steps. Those 1 or 2 steps are critical. We were talking about central line infections in another talk, I think I brought it up. It’s the same thing [here]. 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, “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 3 patients that had endoscopes here.”

But if each physician is only seeing 1 [patient] at a time, nobody’s putting it all together that there’s a problem, because the likelihood of 1 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 difficile [Clostridioides difficile] transmitted to multiple patients through endoscopes. Our goal would be “Wouldn’t it be great if we had disposable endoscopes?” We were talking about that prior to COVID-19 and then all that stopped. So, we have to get back to basics…and start looking at our programs again. Because most likely, during COVID-19, people got out of the routine of cleaning endoscopes; …we weren’t doing [endoscopies] 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 having 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 that person, …making sure there are no steps missed. Maybe I’m doing it and I missed step number 3, and I didn’t even notice it. So, I go on to step 4 or 5 or 6. 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 [adopt the] buddy system, whether it’s for cleaning scopes, decontaminating and sterilizing surgical instruments, or putting on PPE [personal protective equipment]. Somehow, …we have to start having buddies in the hospitals, in clinics, in long-term care, [to] keep an eye on each other and remind each other about infection prevention practices, even hand washing. [When] a physician or nurse or an aide or housekeeper comes 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 tell them that if a person walks out of the room and hasn’t washed their hands, they will be possibly seen and another coworker will say, “Hey, you missed an opportunity to wash your hands.” And the only [way] you can respond is “Oh, thanks for letting me know.” It takes away the meanness that can come out, [such as] “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 they 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 health care workers’ lives and prevent infections in our patients. I think we need to look at health care in a totally different light post–COVID-19…, because we can fix a lot of things before our next pandemic.