Scopes: Industry Advice for Cleaning, Disinfection and Repair

Infection Control Today invited members of industry to share their perspectives on the key issues relating to scope cleaning, disinfection and repair.

What are the most challenging issues related to scope cleaning and sterilization that sterile processing technicians report?

Metrex: Sterile processing technicians are the front line for ensuring that the endoscopes are properly cleaned, disinfected and function according to the manufacturers’ recommendations and industry guidelines. On a daily basis, technicians are met with a multitude of challenges. One such challenge is dried blood and organic matter on reusable endoscopes and other medical devices. This dried matter can impede proper cleaning and disinfection. This coupled with instrument complexities from model-to-model and manufacturer-to-manufacturer, variations in the endoscope itself can lead a reprocessing technician to miss or overlook slight variations in the design and intricacies of the device especially in a high throughput facility where performance is measured on quick turnaround times. Seemingly minor missteps can lead to incomplete cleaning of a device and potentially lead to inadequate disinfection even when following procedures set forth by the facility.

Mobile Instrument Service & Repair: Some of the most common complaints we hear are:
"We don't have a lot of time to reprocess equipment between uses because they are needed back in rotation."
"I am not sure how long my flexible scopes can hang between reprocessing and next use before needing reprocessed again."

Ruhof: In institutions that do not have automated endoscope reprocessors, technicians are required to do manual cleaning on a wide variety of flexible endoscopes from different manufacturers. Not only is it important the clean scopes immediately following use to reduce the amount of microbial bioburden which could lead to a biofilm formation but busy endoscopy suites and ORs require a quick turnover of these semi-critical devices. Technicians are faced with the challenge of knowing the different scopes, their function, connections ports and accessories and most importantly how to effectively manually clean the scopes in preparation for sterilization or high level disinfection. The inner lumens of scopes provide a particular challenge during the cleaning process with different size inner lumens and working channels.Following ANSI/AAMI standards the technician must also be aware of the individual manufacturer’s guidelines and recommendations for the cleaning of the scope. Enzymatic cleaners play a vital role in the cleaning process.

Spectrum Surgical: As more automated endoscope reprocessing units include leak testing and channel flushing in their process, there is growing confusion regarding whether or not the bedside cleaning, leak-testing and pre-cleaning processes may be skipped because these steps are performed “automatically” during high-level disinfection.

SPSmedical: Endoscopes are complex devices that come with detailed and varied reprocessing steps as outlined in each device manufacturer’s instructions for use (IFU). Sterile processing technicians are challenged by complex instruments as they require special training, specific equipment, validated supplies and significant time to complete each reprocessing step.  When sterile processing technicians are provided the resources  necessary to follow best practices, healthcare facilities and patients can expect positive outcomes.  However, when best practices are not followed either knowingly or unknowingly, catastrophic results can occur. 

What are some best practices that can help address these challenges?

Metrex: Even though it is well known that endoscopes should be cleaned immediately after use, sometimes this is not practical or possible. Dried blood and other organic matter can be avoided by keeping the used re-usable instrument wet either by covering with a wetted towel or using a commercially available foaming enzymatic spray to initiate the cleaning process shortly after patient use is important. This helps reduce the amount of time put into re-wetting dried surfaces, helping standardize the cleaning reprocessing time. Engaging the sterile processing technician to determine the best practices and procedures will lead to fewer errors and ultimately lead to better instrument turn around, less stress on the technician and better patient outcomes.
 
Mobile Instrument Service & Repair: If the sterile processing department finds themselves skipping steps or rushing the cleaning processes for instruments/equipment, it may be a result of inadequate inventory. If steps in the pre-cleaning stages are missed or skipped, the sterilization process when applicable will be ineffective. It is very important to follow all steps in reprocessing to ensure patient safety and equipment functions properly. We recommend that equipment hangs no more than five days between reprocessing and next use.    

Ruhof: Technicians should receive initial training and continuing competencies for manual cleaning. Understanding and following manufacturer guidelines they should be provided with all of the tools necessary to do the job such as multi-tiered enzymatic cleaners that have been tested in independent laboratory validation studies. Cleaning sponges and brushes for external and internal cleaning of lumens. Leak testing along with visual inspection after cleaning is an important role but to insure that cleaning practices have been effective a method of validation should be used. Devices that measure ATP (adenosine triphosphate) are an excellent means of not only validating the cleanliness of a scope after cleaning but can provide feedback to the technician about how effective their manual cleaning was. Validation by this method can also be used in developing and maintaining technician competencies.

Spectrum Surgical: Understand that the margin of safety is very thin with regards to the endoscope cleaning process. Even a minor deviation to established scope cleaning and reprocessing protocols can allow bioburden to remain in or on the scope, possibly resulting in patient infections. Adherence to established bedside cleaning and pre-cleaning steps are crucial. Enzymatic detergent and mechanical friction from endoscope cleaning brushes is necessary to loosen and remove biomaterial from the channels when cleaning after a procedure. This is even more critical if there has been a delay between the end of the procedure and the initiation of the cleaning process, as the bioburden will have dried. Dried-on bioburden is more difficult to remove and must be removed mechanically by brushing. Additionally, do not skip the leak test. Leak testing is a critical step to detect potential leaks and prevent fluid invasion. This test must be performed before the scope is immersed or exposed to liquid, as it will be during the cleaning process.

SPSmedical: In healthcare, compliance with reprocessing best practices is critical to ensure patient safety as one of our greatest threats is healthcare associated infections (HAIs). Examples of reprocessing best practices for healthcare facilities, include:  requiring all medical device manufacturers to provide a validated IFU for each of their instruments, providing the reprocessing equipment and supplies required to comply with each manufacturer’s validated IFU, hiring certified technicians and providing continuing education (CE) opportunities for them to maintain their certification, and  a work environment that encourages a questioning attitude. Staff should be encouraged to ask questions if they do not know or are unsure of proper reprocessing steps. Examples of best practices for sterile processing personnel, include: knowing and following each device manufacturer’s validated IFU, speaking up if they do not have the proper equipment or supplies to comply with IFUs, becoming certified (if they were hired without this requirement) and maintaining their certification by participating in CE programs, and finally working with a questioning attitude.