Endoscope Reprocessing Risk and Current Risk Practice

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Endoscopy Reprocessing ;
Risk
and Current risk Practice
BY
Iman M. Abdullah Afifi
IC consultant ASUH
Risk of endoscope reprocessing
patient HCW
Environment
On patient
1- Infection
2-Irritation and inflammation from
chemicals if not adequately rinsed
after biocide
On HCW
Exposure to infectious microorganisms
contained in the aerosol
Exposure to chemicals contained in the
aerosol
- Eye irritation
- Respiratory irritation/sensitization
- Skin irritation/sensitization
On environment
Environmental contamination due
to aerosols from the cleaning
process being dispersed and
deposited throughout the area
To avoid risk on HCW
STANDARD PRECAUTIONS
IMMUNISATION
TUBERCULOSIS
Negative pressure ventilation
N95 respirator should be
worn by staff during
the bronchoscope
During recovery phase if
coughing, patients should be provided
with a close fitting, disposable
particulate filter respirator that does not
have an exhalation valve.
To avoid risk on the patient
Adequate and correct reprocessing
cleaning , disinfection and
sterilization
Endoscope Reprocessing
Two classifications of Endoscopes
Critical Endoscope:
Endoscopes used in the examination of critical
spaces such as joints and sterile cavities.
Many of these endoscopes are rigid with no
lumen as arthroscopies and laparoscopes
Semi critical Endoscope
Fiber optic or video endoscopes used in the
examination of the hollow viscera. These
endoscopes generally invade only semi critical
spaces, although some of their components
might enter tissue or other critical spaces i.e..
Forceps. As colonoscopies, gastro scopes,
Duodenoscopes, sigmoidscopes,laryngoscopes,
nasopharyngeal endoscopes and enter scopes.
Opinions differ regarding the reprocessing

requirements of bronchoscopes; a minimum of
high level disinfection is required
Reprocessing of Endoscopes
1. Pre-cleaning
2. Test for leaks
3. Manual cleaning
4. Disinfect
5. Rinse
6. Dry
7. Store
Reprocessing Flexible Endoscopes and
Accessories
The most important step in endoscope
reprocessing is manual cleaning prior to
disinfection.
Endoscopes that have not been well cleaned
will not be adequately disinfected or
sterilized - even with prolonged exposure
times.
If an item cannot be cleaned, it cannot
be disinfected or sterilized.
In the examination room
immediately after the procedure:
Prepare for bedside cleaning:
 PPE
 Container with enzymatic
 Sponge or lint-free cloth
 Air and water channel cleaning adapters per
manufacturer’s instruction
 Protective video cap
1. Wipe the insertion tube
with a disposable Sponge or
lint-free cloth dampened in
freshly prepared enzymatic
detergent solution.
Note that
the cloth / sponge
should be disposed of
between cases
2. Aspirate enzymatic detergent solution through
the suction/biopsy channels , alternate
suctioning enzymatic solution and air several
times until the solution is visibly clean – Finish
by suctioning air
Note: Alternate suctioning of fluid and air is

more effective than suctioning fluid alone in
the removal of debris from lumens –
immediate flushing of the biopsy/suction and
air/water channels precludes drying of debris
on lumen surfaces
3. Flush or blow out air and water channels in
accordance with the endoscope manufacturer’s
instructions
4. Flush the auxiliary water channel
5. Detach the endoscope from the light source and
suction pump
6. Attach protective video cap if using a video
endoscope
7. Transport the Endoscope to the reprocessing
area in an enclosed container
Note: Containers, sinks, and basins should be large
enough that the endoscope will not be damaged by
being coiled too tightly
8. ULTRASONIC CLEANING
Handling and Transport
Covered containers with
easily cleanable cover
 Transport solid endoscopes
directly where cleaning
will be performed
 Cleaned transport containers
after each use
Area of Reprocessing
Area must be designated
and dedicated
Adequate ventilation-
capable of removing toxic
vapors from cleaning/
disinfectant agents.
Minimum of 10-12 air
exchanges per hour in the
reprocessing area.
Sterile or filtered tap water
should be available in the
area.
Sink size 40X40X60 cm
Cleaning the Endoscope in the Reprocessing
Area
Prepare the following:
 PPE
 Leakage testing equipment
 Channel cleaning adapters
 Large basin of endoscope detergent
solution
 Channel cleaning brushes
 Sponge or lint-free cloth
Leakage Testing
Leak Testing detects damage to the interior
or exterior of the endoscope
The leak test is done before immersion of
the endoscope in reprocessing solutions to
minimize damage to parts of the endoscope
not designed for fluid exposure.
The leak test involves
applying air pressure to
the inside of the endoscope
insertion tube and then
watching for air bubbles
denitrifying leaks.
If damage is detected,
the equipment should not reused ,
labeled and the manufacture should
be consulted.
Manual cleaning
All of the channels

should be irrigated and
brushed, if accessible, to
remove particulate matter.
Irrigation adapters
should be used to facilitate
cleaning of all channels.
All immersible parts of
the endoscope should then
be rinsed with water.
Wash all the debris from the exterior of the
endoscope by brushing and wiping the
instrument while submerged in the detergent
solution. Note that the instrument should be left
under water during the cleaning process to
prevent splashing of contaminated fluid and
aerosolization of bioburden
After each passage, rinse the brush in enzymatic
solution, removing any visible debris before
retracting and reinserting it
Continue brushing until there is no debris visible
on the brush
Detergent solutions should be discarded after
each use. Cleaning brushes should be
disposable or thoroughly cleaned and receive
high-level disinfection or sterilization after each
use.
Attach the endoscope cleaning adapters for
suction, biopsy, air, and water channels
Note: Automated pumps are available for this
step that eliminate the manual flush
Attach the manufacturer’s cleaning adapters for special
endoscope channels (dual channel, elevator channel,
auxiliary channel)
To achieve adequate flow through all lumens, various
adapters or channel restrictors may be required
The elevator channel of a duodenoscope is a small
lumen, this channel requires manual reprocessing using a
2-5mm syringe
Flush all channels with the detergent
solution to remove debris
Soak the endoscope and its internal channels
for the period of time specified by the label
If immediate reprocessing is not possible the
endoscope should be leak-tested, flushed,
brushed, and allowed to soak in a enzymatic
solution until it can be thoroughly
reprocessed
High Level Disinfection
 Recognized as the standard of reprocessing for
endoscopes by:
 CSGNA / SGNA
 CPSO – College of Surgeons of Ontario
 ASGE – American Society for Gastrointestinal
Endoscopy
 ACG - American College of Gastroenterology
 AGA - American Gastroenterological Association
 APIC - Association for Professionals in Infection
Control and Epidemiology
 CDC – Centers for Disease Control and Prevention
Glutaraldehyde can be used in manual
and automated reprocessing
protocols.
If glutaraldehyde is used,

all immersible internal and
external surfaces should be
in contact with the disinfectant
for not less than 20 minutes to
achieve high-level disinfection.
After chemical disinfection, endoscopes must be rinsed with sterile
water or with tap water followed by 70% ethyl or isopropyl alcohol

APIC guideline for infection prevention and control in flexible endoscopy.
rinse.
The instrument and its channels should be thoroughly air-dried. A
final drying step that includes flushing all channels with alcohol
followed by purging the channels with air greatly reduces the
possibility of recontamination of the endoscope by waterborne
microorganisms.
Note Drying the endoscope after every
reprocessing cycle, both between
patient procedures and before
storage is a requisite practice crucial
to the prevention of bacterial
transmission
Drying is as important to the
prevention of disease transmission as
cleaning and high level disinfection
Risks associated with contaminated water
The organisms will proliferate in damp areas

of the endoscope during storage --------
colonization of endoscopes and disinfecting
machines
Atypical mycobacterium are frequently
present in tap water. Rinsing of
bronchoscopes after disinfection should be
with sterile/filtered water.
Automatic Flexible Endoscope
Preprocessor
The potential advantages of AFERs include:
Standardization of endoscope reprocessing.
Reduced exposure of HCWs to hazardous chemicals.
Reduction of staff time spent on reprocessing.
Endoscope reprocessing machines need to be
regularly cleaned and maintained to prevent
colonization and formation of biofilms that could
contaminate the instruments processed therein.
Automatic Flexible Endoscope Preprocessor
Water supply Drying

Fume containment Individual channel
Biocide supply perfusion
Self-disinfection Maintenance
Leak testing Microbiological
Warning systems monitoring
Proof of process Cycle counter
Ensure that the endoscope and endoscope
components are compatible with the automated
endoscope reprocessor (AER)
AER provide a method by which a permanent
record of endoscope use and reprocessing can be
monitored and validated
Some AER have a system capable of tracking
endoscopes and patients. For each procedure
the patients name and record number, the date
and time of procedure, type of procedure, the
endoscopist and the serial number of the
endoscope are recorded and stored to assist in
outbreak investigation.
Sterile water should be used to
fill the water bottle.
The water bottle and its connecting tube
should be sterilized or receive high-level
disinfection at least daily.
Machines should be plumbed into the water
supply rather than use manual filling.

It will be necessary to install pre-filters,
i.e. filters in the water supply prior to its entry
into the automatic disinfector.
Filter systems must be regularly disinfected,
serviced and monitored. Filters themselves may
easily become a source of contamination.
https://
www.getinge.com/int/solutions/sterile-
reprocessing/endoscope-reprocessing
/
https://youtu.be/AU0uYwRTAzs
https://youtu.be/vAFUWHtMpVA
https://youtu.be/RvkXWM6dw0k
Gas plasma sterilization
Instruments with very long narrow
lumens, and those closed at one end, are
unsuitable for sterilization using
hydrogen peroxide gas plasma. Some
shorter flexible endoscopes and
accessories have been validated for
sterilization with this system.
Storage
Endoscopes should be stored
in a manner that will protect
the endoscope and minimize
the potential for accumulation
of residual moisture.
They should not be coiled or stored
in cases that cannot be properly
cleaned.
Endoscopes should
be hung in a vertical
position to facilitate
drying.
Endoscopes should
not be stored in
transport cases as
these may DONOT
themselves become REASSEMBLE
contaminated. THE ENDOSCOPE

Type of Endoscope Storage Time
Gastro scopes, colonoscopies and 72 hours
radial EUS enter scopes
Enteroscopes 72 hours if stored with

continuous air flow.
12 hours if hanging storage, as
impractical to have hanging
vertically without touching the
floor.
Duodenoscopes, bronchoscopes 12 hours

and linear EUS scopes
Emergency endoscopes e.g. 72 hours, but preferably just

intubating bronchoscopes before use if time permits
Reusable accessories
that penetrate mucosal
barriers (e.g., biopsy
forceps, cytology
brushes) should be
mechanically cleaned
(i.e., by ultrasonic) and
then steam sterilized
between each patient
or used once and
discarded.
Note:
APIC guideline for infection prevention and control in flexible endoscopy.
A log should be maintained indicating for each

procedure the patient's name and medical
record number, the procedure, the
endoscopist, and the serial number or other
identifier of the endoscope used.

Endoscope Reprocessing Risk and Current Risk Practice

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What are the risks of endoscope reprocessing to patients, healthcare workers and the environment?

What are the risks of endoscope reprocessing to patients, healthcare workers and the environment?

What steps are involved in reprocessing endoscopes?

What steps are involved in reprocessing endoscopes?

`

Opinions differ regarding the reprocessing

Note: Alternate suctioning of fluid and air is

All of the channels

If glutaraldehyde is used,

water or with tap water followed by 70% ethyl or isopropyl alcohol

The instrument and its channels should be thoroughly air-dried. A

followed by purging the channels with air greatly reduces the

possibility of recontamination of the endoscope by waterborne

The organisms will proliferate in damp areas

Water supply Drying

fill the water bottle.

The water bottle and its connecting tube

should be sterilized or receive high-level

disinfection at least daily.

Machines should be plumbed into the water

supply rather than use manual filling.

Enteroscopes 72 hours if stored with

Duodenoscopes, bronchoscopes 12 hours

Emergency endoscopes e.g. 72 hours, but preferably just

A log should be maintained indicating for each

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