Endoscope reprocessing that is not properly performed has deadly consequences. For example, the carbapenem-resistant Enterobacteriaceae (CRE) outbreak that occurred at the Virginia Mason Medical Center in Seattle left 32 patients sick. CRE is a drug-resistant bug that was spread to people who underwent endoscopic retrograde cholangiopancreatography (ERCP) between 2012 and 2014 at the Virginia Mason center due to duodenoscopes that were not properly disinfected. As a result, 11 of the 32 patients died.
Despite being hard to clean, duodenoscopes are not the only medical equipment that has been linked to deaths due to improper disinfection techniques. According to a 2018 study published in the Journal of Infection Control, approximately 22% of endoscopes examined had organic contamination in them and 77% had microbial growth. The study indicated that these results occurred at three hospitals after reviewing their reprocessing, drying, and storage processes.
According to president and CEO of independent research organization Ofstead and Associates in St. Paul, Minnesota, Cori Ofstead, the study indicated that there were problems with the effectiveness of reprocessing for all endoscopes, not just the complex ones. One study found that the ability of bacteria to form biofilms on the inner channels of surfaces may lead to failed decontamination processes (1).
Additionally, many modern endoscopes can’t be sterilized by heat and contain multiple channels, which makes them even harder to clean. This is why it’s important to implement microbial surveillance of endoscope reprocessing to determine early formation and colonization of biofilm before it affects patients.
Is Production Pressure and Staff Shortage To Blame?
Endoscope reprocessing failures were named at one of the top 10 healthcare technology hazards in 2018 by a nonprofit organization that focuses on safety improvement in healthcare settings known as the ECRI. Many of these problems exist due to staff shortage and an overwhelming production pressure to turn over these devices, said James Davis, MSN, RN, certified healthcare environmental manager and senior infection prevention analyst at ECRI Institute.
Davis stated that hospitals have to choose between having enough equipment to support patient load and forcing staff to reprocess equipment up to 10 hours a day. In these scenarios, you’re more likely to make mistakes as a human being and contaminate both yourself and the scope, said Davis. He continued by saying that people need to understand the whole process, including leaving the bedside to reprocessing to hanging the equipment in the cabinet ready for use. It takes longer than expected to clean one piece of equipment (even hours) if you do it properly, especially if you are following the instructions for use (IFU).
At the University of Cincinnati Medical Center’s Division of Digestive Diseases, the reprocessing cycle takes around 40 minutes. However, this time may vary depending on how complicated the scope is. According to Milton Smith, MD, the most important part of reprocessing starts after the procedure right at the patient’s bedside. He stated that it is so important to perform enzymatic bedside cleaning before any debris accumulates on the scope. Then, the computerized system requires an additional 30 to 40 minutes to fully clean the scope. The department maintains about 80 scopes per day, including specialty scopes, to ensure that there is no additional pressure on staff to clean the scopes. This allows the department to meet its caseload of up to 30 patients per day.
Defining the Cleaning Process
Nurse manager Michelle Armstrong said that the team processes their own scopes right in the endoscopy unit. The reprocessing center is located centrally to procedure rooms. They have a dirty side and a clean side so that the process can flow as needed. For example, a technician starts on the dirty side of the room and moves all of the equipment to the clean side before loading the scope into a washer. Afterwards, the tech moves the equipment to the clean side of the room where it is blown out and hung in the storage closet. Davis recommends that health care centers audit their cleaning processes regularly by starting with the moment the procedure is completed.
Davis stated that the process should be seamless from the immediate manual flushing of the scope to prevent anything from accumulating on the scope during setup. He indicated that the staff should be flushing the scope initially with the proper enzymatic cleaner to break down biological matter and proteins. Then, as the tech moves the scope to the washer, they should take precaution not to contaminate the washer lid. They also need to use the proper alcohol and air flushes when the scope comes out of the washer. Staff should also be hanging the equipment in the cabinet the proper way so that no fluid is collecting in the tubs and no tips are touching the bottom of the cabinet. Davis stated that he has seen scopes rolled up like garden hoses and that’s how contamination grows in the fluid.
Tracking and Managing The Cleaning Process
The GI Associates Endoscopy Center located in Wausau, Wisconsin, keeps 14 colonoscopes and eight gastroscopes as well as a radical and linear EUS scope for special procedures on hand. Endoscopy tech Amanda Jenson stated that the center washes about 8,000 scopes per year. She stated that they track their reprocessing and scope use by documenting the scope re-processor, scope identification number, physician, and patient ID number within a reprocessing computer system. The staff uses a marked bin system for daily use and transport to ensure that the next scope to be used is the one that has been drying the longest.
Jenson stated that after they have gone through the pre-cleaning steps and the scope has completed its cycle (including air drying), the staff uses a syringe to manually push air through it. This helps ensure that the scope is dry. They also double check all computer steps and dry off the scope with a lint-free cloth before putting it away. Jenson said they stack the bins on a transparent cart. They mark the scope that has been drying the longest with a clothespin. When the scope is being used, they take the clothespin and move it to the next bin. At the end of each day, the clean scopes are stored in an airflow cabinet.
Proper Reprocessing Protects The Patient
There are three endoscopy centers throughout the Denver, Colorado metro area. At Rocky Mountain Gastroenterology, which is the largest GI healthcare center in Colorado, the ambulatory surgery centers do not perform specialty procedures. They only do upper endoscopies and colonoscopies. The center maintains 12 scopes, including seven colonoscopy scopes and five upper endoscopy scopes, at each of their three centers.
Nurse Laura Falcon stated that each center does up to 34 procedures per day. Each location contains four endoscopy technicians to help the physicians. There is one in each procedure room and two in the processing room. The tech in the procedure room does the pre-cleaning with enzymatic water. Then the tech takes the equipment to the processing room in a transparent bag.
The equipment is considered “contaminated” and it stays with the same “dirty” tech to ensure that it is not spread to other equipment. Then, a “clean” tech brings the clean scope into the next patient. The healthcare center also keeps their patients safe by implementing a process that double checks the clean scope that is brought into the room. Staff places the print out with the clean scope’s serial number in a holder that is attached to the scope. This ensures that the equipment has undergone all processes before exposing the patient. For example, if a nurse relieves a tech that went on break, he or she can check that the scope is safe to use.