September 27, 2013 — This article by Lawrence F Muscarella, PhD, provides a step-by-step protocol that he developed and that may be (but is not necessarily) suitable for “prepping” a gastrointestinal (GI) endoscope (or of another type of flexible endoscope or comparable reusable medical instrument) prior to its delayed reprocessing.
A number of caveats and restrictions, which are discussed below, apply to this protocol.
Prior to performing the protocol detailed below, or the manufacturer’s procedure[4] or another comparable one, however, it is recommended that the practitioner be circumspect and first discuss with the instrument’s manufacturer(s) the appropriateness of delayed reprocessing and whether a procedure — such as the one provided below — that includes the GI endoscope’s prolonged immersion in a detergent solution is suitable or might instead damage the instrument and void its warranty.
Failure to clean and high-level disinfect (and dry) the GI endoscope promptly after its clinical use may result in the drying of patient materials, ineffective reprocessing and damage to the GI endoscope voiding its warranty.[1-7,10-14] — Lawrence F Muscarella PhD
Step-by-step protocol
The following is a step-by-step set of instructions that may be suitable for “prepping” a GI endoscope prior to its delayed reprocessing.†
These instructions are applicable to GI endoscopes (or another type of flexible endoscope or comparable reusable medical instrument):*
(a) that have not yet been pre-processed one hour after the GI procedure;
(b) that were pre-processed promptly after the GI procedure, but have not yet been terminally reprocessed one hour later;
(c) whose surfaces are suspected of being contaminated with dried and hardened patient debris and materials; and/or
(d) that were used during a procedure with excessive bleeding.[4-6,13]
Quality and Safety Services and Case Reviews for Hospitals, Manufacturers, Patients: Click here to read about Dr. Muscarella’s quality and safety services committed to reducing the risk of healthcare-associated infections, including CRE outbreaks linked to contaminated endoscopes and other reusable medical equipment.
1. Leak-test the GI endoscope in accordance with its manufacturer’s instructions. If the endoscope fails this test, do not proceed to Step 2A. Instead, refer to the GI endoscope’s instructions for information about its repair. Leak testing is important to reduce the likelihood of endoscope damage, fluid invasion and disease transmission.
- The more complete article (in PDF format) entitled “The delayed reprocessing of gastrointestinal endoscopes and bronchoscopes” on which this blog’s article herein is based may be downloaded by clicking here.
2A. Fill a clean basin with fresh, potable tap water.
- Ensure the basin (or sink or tub) is sufficiently wide and deep: (i) to accommodate and not place undue stress on the coiled GI endoscope’s insertion tube and umbilical cord; and (ii) to immerse the entire GI endoscope,including its control head, in water.
- Determine the approximate volume of water in the basin (in gallons), which is necessary for Step 2B.
- Note: The authors of a recently published scientific report conclude that a delay of the GI endoscope’s washing after its use may have resulted in the instrument’s drying, possibly explaining transmission of Klebsiella pneumoniae carbapenemase-producing bacteria.
2B. Add a measured concentrate of detergent that is appropriate for the filled basin’s estimated volume of water. Read the detergent’s labeling and instructions for use.
- Ensure that the enzymatic (or non-enzymatic) detergent is not only specifically labeled for cleaning GI endoscopes,[6] but also is compatible with and will not damage the GI endoscope’s materials and components during prolonged immersion (for as many as 10 hours) in the detergent solution.
- If the detergent’s labeling requires its mixing with warm or hot water, then a method or device, such as an immersion heater, would seemingly be necessary during the GI endoscope’s prolonged immersion to maintain the detergent solution at this elevated temperature, lest the detergent solution’s temperature drop to room temperature (which is 68o F) over time, possibly become ineffective, and not loosen patient debris that dried and hardened on the endoscope’s surfaces. Alternatively, a detergent labeled for use in water at room temperature may be considered.
- As a confirmation, users may consider requesting of the detergent’s manufacturer a statement certifying materials compatibility and the detergent’s effectiveness during prolonged immersion for loosening hardening debris from a GI endoscope’s surfaces at the detergent label’s indicated water temperature.
Two related, “recommended” articles by Dr. Muscarella:
3. Completely immerse the carefully coiled GI endoscope in the detergent solution.
- To avoid costly damage, it likely will be necessary to securely attach one or more water resistant caps to the GI endoscope’s electrical connectors (or, if featured, a “UPD scope connector”)(6) before immersing the GI endoscope in the detergent solution. Refer to the GI endoscope model’s operating manual (or reprocessing instructions) for more information.
- Remove from the GI endoscope and immerse in the detergent solution the suction and air/water valves and other detachable, reusable parts.
4A. Manually flush and fill each of the immersed GI endoscope’s accessible channels with this detergent solution using the required reprocessing adapters, plugs, tubes, and other accessories.
- These channels include the suction, air, water, and, if featured, auxiliary water channels (possibly in addition to other channels). Refer to the endoscope’s operating instructions for a description of these reprocessing adapters and accessories, which were included with the GI endoscope’s original purchase.
- Different models and types of GI endoscopes may require the use of different types of reprocessing adapters, plugs, tubes, and other accessories.
4B. Detach from the GI endoscope (and remove from the basin) each of these reprocessing adapters, plugs, tubes, and other accessories. Cover the basin.
5A. Soak the immersed GI endoscope (and its valves and other reusable parts) in the detergent solution for as long as required—for example, until hardened debris is loosened or trained staff become available to terminally reprocess the endoscope, but not for longer than 10 hours.[6]
- Again, use the detergent solution at the temperature (and concentration) indicated on its labeling.
- The use of a timer to ensure that the GI endoscope is not immersed for longer than 10 hours is recommended, as is the use of a log book to record the frequency of the GI endoscope’s prolonged immersions.
5B. After its prolonged immersion, remove the GI endoscope (and its valves and other reusable parts) from the detergent solution.
6. Thoroughly clean and terminally high-level disinfect (or sterilize) and dry the GI endoscope (including its valves and other reusable parts) in accordance with the instructions provided by the GI endoscope’s manufacturer.
- If using an automated endoscope reprocessor, refer to its labeling and operating instructions to minimize redundancy while ensuring that every necessary manual reprocessing step is performed.*
Footnotes:
† This article’s “prepping” protocol was adapted from instructions published by a manufacturer, who recommends, along with a number of other caveats, that the prolonged immersion of its GI endoscopes in a detergent solution be performed “only when necessary,” not routinely.[4] Extended immersions should be avoided and may damage the GI endoscope when performed consecutively.[4-6,13] This protocol’s Steps 2-5 are additional measures and are not replacements for manual cleaning or terminal reprocessing of the GI endoscope (as detailed in Step 6, above). This box article is not an endorsement of delayed reprocessing. Refer to Dr. Muscarella’s article about delayed reprocessing for more details about the practice.
* Unless the manufacturer advises otherwise, this “prepping” procedure is not to be performed for any other application. Some manufacturers of GI endoscopes may contraindicate delayed reprocessing. Therefore, before performing this procedure, contact the manufacturer of the GI endoscope (or of another type of flexible endoscope or comparable reusable instrument) to confirm its acceptability, safety and effectiveness. For some reusable instruments whose manufacturers might condone this procedure, additional or fewer steps may be necessary.
References are available by clicking here.
Article by: Lawrence F Muscarella, PhD, posted on 9-27-2013; updated 10/1/2015, Rev A.