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CORRECT ENDOSCOPE REPROCESSING

Christina BradleyLaboratory Manager

Hospital Infection Research LaboratoryQueen Elizabeth Hospital

Birmingham

HIRL Birmingham

�“Inadequate decontamination procedures and equipment malfunction were two leading causes of post endoscopic infection and contamination. More than 91% of the infections could be prevented if quality control systems were improved”

Kovaleva J et al Clin Microbiol Rev 2013;26(2):231-54

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Transmission of infection by flexible gastrointesti nal endoscopy and bronchoscopy

TYPE OF FLEXIBLE ENDOSCOPIES

No. of REPORTED

INFECTIONS/OUTBREAKS

REASONS FOR FAILURE

BRONCHOSCOPY 51 • Inapprpopriate cleaning and disinfection – povidone iodine• Contaminated AER• Incorrect connectors• Rinsing with tap water• Hole in the endoscope sheath (no leak testing)

ERCPEndoscopic Retrograde CholangioPancreaticography

23 • Inapprpopriate cleaning and disinfection – povidone iodine, cetrimide• Contaminated AER• Incorrect connectors• Failure to irrigate all channels• Rinsing with tap water• Contaminated water bottle

UPPER GASTROINTESTINAL ENDOSCOPY

19 • Inapprpopriate cleaning and disinfection – povidone iodine• Contaminated AER• Incorrect connectors• Rinsing with tap water• Hole in the endoscope sheath (no leak testing)

SIGMOIDOSCOPY &COLONOSCOPY

5 • Inapprpopriate cleaning and disinfection – povidone iodine, BKC, cetrimide• Contaminated AER• Incorrect connectors• Contaminated water bottle• Biopsy forceps not sterilized

Kovaleva J et al Clin Microbiol Rev 2013;26(2):231-54

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DECONTAMINATION OF FLEXIBLE ENDOSCOPES

�Meticulous cleaning�Proper immersion in disinfectant�Thorough rinsing after disinfection

�Endoscope Washer Disinfectors are the preferred option

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ENDOSCOPE DECONTAMINATION PROBLEMS

� Instruments and accessories are expensive� Damaged by heat and pressure� Complex, difficult to clean and dry� Penetration of channels uncertain� Rapid throughput� Risk of recontamination during final rinse

from water supply/EWD

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ENVIRONMENT DESIGN AND LAYOUT

� Designated and dedicated decontamination area

� Separate dirty, clean and storage areas� One-way flow for equipment� Suitable facilities for manual cleaning� Dedicated hand wash basin

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ENDOSCOPE CHANNELS

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DECONTAMINATION STAGES

�Pre clean at patient bed side�Leak test�Manual clean�Endoscope Washer Disinfector�Storage

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CLEANING

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PRE CLEANING

� At point of use– Air/water channel– External surfaces– Suction channel

� Manufacturers instructions areessential

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MANUAL CLEANING� At the sink in dedicated decontamination room

– Brushing Flushing

� Single use brushes must be used for cleaning at all times (UK recommendation)

� Staff must ensure meticulous adherence to manufacturers instructions for cleaning

Important to ensure� Access to all channels whether they have been used or not e.g. forceps

raiser channel, auxiliary water channel� Irrigation of all channels that cannot be brushed

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DISINFECTANTS

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ENDOSCOPE DISINFECTANTS

�Glutaraldehyde�Peracetic acid�Chlorine dioxide�Superoxidised water�OPA�Etc, etc ……….

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DISINFECTANTS AND ENDOSCOPE DECONTAMINATION

Ensure disinfectant�has broad spectrum of antimicrobial

activity� is compatible with instruments and

processing equipment� is used at effective concentration� is in contact with all surfaces

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CHANNEL IRRIGATION DEVICES

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ENDOSCOPE DECONTAMINATION : POTENTIAL PROBLEMS

� Disinfectant– Spectrum of activity– Over use

� Water quality– Bacterial contamination– Chemical contamination

� Training� Accessories e.g. water bottle, biopsy forceps

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BACTERIA FREE WATER

�Cystoscopes�Bronchoscopes�ERCP

�Potential for infection and/or misdiagnosis of infection

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ENDOSCOPE WASHER DISINFECTORS

The WD440 machines:The WD440 machines:

�Single chamber �Twin chamber (independent operated)

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ENDOSCOPE WASHER DISINFECTORS : PROBLEMS

�Disinfectant concentration�Machine contamination�Water quality�Maintenance�Validation

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ENDOSCOPE STORAGE

Endoscopes which have been reprocessed by high level disinfection and have been left for periods >3 hours should be reprocessed.

MDA DB2002(05)

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TRANSPORTATION

�Protection of endoscopes and the environment from contamination and/or possible damage

�Separation of dirty and clean endoscopes

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DOCUMENTATION

Types:-� Policies: Statement of intent e.g. ‘We will “Provide

decontaminated endoscopes”� Procedures: Sets of instructions – How policy

is implemented e.g. ‘How to decontaminate endoscopes’

� Forms: Evidence that procedures are carried out. e.g. ‘List of items processed’

� Others: Info, Guidelines, standards etc

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STANDARD OPERATING PROCEDURES

� Purpose of SOPs– SOP’s are required for all tasks which could have an

effect on the quality of the decontamination process

� SOP’s– Must clearly describe specific tasks– Must be easy to understand– Must change if the task changes– Are an essential tool in training

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STAFF TRAINING

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STAFF TRAINING

� At induction and regular updates� Anatomy/construction of endoscopes� Use of washer disinfectors (if applicable)� Traceability systems� Importance of decontamination record

keeping

� Records kept of individuals training� Sufficient time allowed for training

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SUMMARY

It is important to ensure that� Staff receive comprehensive training � Cleaning takes place prior to sterilization or

disinfection� All surfaces of the endoscope are exposed during the

decontamination procedure� An effective disinfectant is used at the correct

concentration� The final rinse does not re-contaminate the

endoscope� Testing, in accordance with national guidance, takes

place and is audited

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