Is Production Pressure Contributing To Scope Cleaning Gaps?

By Gina Shaw

When endoscope reprocessing is not performed properly, there can be devastating effects. A classic example of this is the outbreak of carbapenem-resistant Enterobacteriaceae (CRE) that occurred among patients at Virginia Mason Medical Center in Seattle. The drug-resistant superbug was spread among 32 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) at Virginia Mason between 2012 and 2014, via improperly disinfected duodenoscopes. Eleven of the patients died.

Although duodenoscopes are notoriously challenging to disinfect, they are not the only scopes that have been associated with outbreaks due to improper cleaning. In a study published in the Journal of Infection Control in April 2018 (2018;46[6]:689-696), an independent organization evaluated the endoscope reprocessing, drying and storage practices of three multispecialty hospitals. They found organic contamination in 22% of the endoscopes examined and microbial growth in 77% of them.

“This study identified problems with reprocessing effectiveness for all types of flexible endoscopes, not just the complex gastrointestinal endoscopes with elevators,” said Cori Ofstead, the president and CEO of the independent research organization Ofstead & Associates, in St. Paul, Minn.

Production Pressure a Factor

In 2018, the international ECRI Institute, a nonprofit focused on health care quality and safety improvement, named endoscope reprocessing failure as one of its top 10 health technology hazards of 2018.

Why do these problems persist, and what can be done about it?

“The biggest issue we see with endoscope reprocessing is a lack of inventory and staff having wicked production pressure to turn these scopes over. Do you have enough equipment to support patient loads, or are you forcing staff to continually be reprocessing all day long, eight to 10 hours a day, because you don’t have enough inventory of the correct scope?” asked James Davis, MSN, RN, a certified health care environmental manager and senior infection prevention analyst at ECRI Institute. “If you have one ECRP scope and 16 of those procedures scheduled that day, what’s going to happen?” Mr. Davis added. “In that scenario,” he explained, “you’re more apt as a human being to make mistakes and contaminate yourself and the scope. The people at the top need to understand that the whole process, from leaving the bedside through reprocessing to hanging in the cabinet ready for use doesn’t take five minutes if you’re doing it right. If you are properly following the instructions for use (IFU), depending on the process and reprocessing equipment, it can take hours or more to do certain scopes properly.”

Reprocessing Continuum Starts at the Bedside

In the Division of Digestive Diseases at the University of Cincinnati Medical Center, the reprocessing cycle typically takes approximately 40 minutes, although that varies based on the complexity of the scope, according to gastroenterologist Milton Smith, MD. “The most important part starts at the bedside after the procedure,” he stressed. “It’s so important to do enzymatic bedside cleaning before any debris can dry on the scope. Then our computerized system takes about 30 to 40 minutes to run a scope through.”

To ensure there is no issue with running out or falling behind and putting pressure on the reprocessing team, the department maintains an inventory of about 80 scopes, including specialty scopes, for its caseload of 25 to 30 patients per day.

“We reprocess our own scopes right here on the endoscopy unit,” said nurse manager Michelle Armstrong. “The reprocessing facility is centrally located to all procedure rooms, and it has a ‘dirty’ and ‘clean’ side, with everything flowing from dirty to clean. The tech starts on the dirty side and does all their manual cleaning before loading the scope washers up. Once that is done, they move to the clean side: the drying and blowing out process and hanging in the closet for storage.”

Mr. Davis recommended that institutions regularly audit their reprocessing system—a continuum that starts from the moment the procedure is completed. “The process should be seamless from that moment, beginning with immediate manual flushing to prevent a bioburden from setting up on the scope. Are the staff flushing the scope initially with the right enzymatic cleaner to break down proteins and biological material? Then, as they are transferring the scopes to the washer, are they doing so without contaminating the washer lid? Are they using the proper alcohol and air flushes when the scopes come out of the washer? Are they hanging in the cabinet the right way—not looped so fluid is collecting, or with tips touching the bottom of the cabinet? We’ve seen scopes rolled up like garden hoses, channeling fluid where contamination will grow.”

The GI Associates Endoscopy Center, in Wausau, Wis., maintains an inventory of 14 colonoscopes and eight gastroscopes, along with a linear and radial EUS scope for special procedures. “We probably wash 8,000 scopes a year,” endoscopy tech Amanda Jensen said. “We track our scope use/reprocessing by documenting the scope reprocessor, physician, scope identification number and patient ID number within our reprocessing computer system.”

For daily use and transport, a marked bin system is used to ensure that the next scope to be used is the one that has been drying the longest. “After we’ve gone through all our pre-cleaning steps and the [automated endoscope reprocessor] has completed its cycle including air drying, we then use a syringe to manually push air through the scope to ensure that it’s really dry. We finish by double-checking all computer steps and dry the scope off with a lint-free cloth before putting it in a clean bin,” Ms. Jensen said. “We stack the bins on a transport cart, and the bin with the scope that has been drying longest is marked with a clothespin. When that scope is taken, the clothespin moves to the next bin down.” At the end of the day’s cases, clean scopes are stored in an airflow cabinet.

Rocky Mountain Gastroenterology, the largest GI group in Colorado, has three endoscopy centers throughout the Denver metropolitan area. Its ambulatory surgery centers do not perform specialty procedures, only colonoscopies and upper endoscopies. “We maintain 12 scopes—seven colonoscopy and five upper endoscopy—at each of our three centers,” the group’s nurse manager Laura Falcon, RN, said. “Each center does approximately 28 to 34 procedures a day—the higher number if we do a double. We have a similar setup at each location, with four endoscopy technicians assisting the physicians—one in each procedure room and two in the reprocessing room. In the procedure room, the tech does the pre-cleaning with enzymatic water and takes the equipment into the reprocessing room in a transport bag. They are then considered ‘contaminated’ and work mainly with the used scope, staying ‘dirty’ throughout the whole process. A ‘clean’ tech will then bring the clean scope in to the next patient.”

Rocky Mountain recently implemented a process for double-checking that a scope is clean when it is brought into the procedure room, by placing the printout with the clean scope’s serial number into a badge holder clipped to the scope.

“If I have a nurse who relieves a tech for lunch, for example, she’ll be able to check that that scope has gone through reprocessing and is safe for the next patient,” Ms. Falcon said.