Disinfecting endoscopes immediately before the first patient of the day

Endoscopic shuffling, infection control, and the clinical practice of push enteroscopy

Failure to identify and diagnose the site and cause of obscure bleeding or some other gastrointestinal disorder may be an indication for push enteroscopy. During this procedure, a long, narrow, flexible gastrointestinal endoscope, known as a push enteroscope, is advanced into the upper gastrointestinal tract to examine and evaluate the proximal section (first one third) of the small bowel. Because of limited funding and inadequate instrument availability, some gastrointestinal endoscopy units may perform this procedure using a colonoscope instead of a push enteroscope. Although not specifically designed for push enteroscopy, colonoscopes are less expensive than push enteroscopes and readily available for clinical use in virtually every gastrointestinal endoscopy unit. The use of a colonoscope or other lower gastrointestinal endoscope to perform push enteroscopy or another upper gastrointestinal procedure (or the use of an upper gastrointestinal endoscope to perform a lower gastrointestinal procedure) is defined in this article as endoscopic shuffling. Although it is arguably efficient and cost effective (and in some instances may improve clinical outcomes), endoscopic shuffling raises a number of economic, legal, medical, and ethical questions and concerns, several of which are discussed in this article, with a particular focus on infection control.

Inconsistencies in endoscope-reprocessing and infection-control guidelines: the importance of endoscope drying

INTRODUCTION

Endoscope reprocessing is a multi-stepped process that renders a contaminated endoscope safe for reuse. Its steps include meticulous cleaning, complete immersion in a liquid chemical sterilant (LCS) or disinfectant to achieve high-level disinfection (or "liquid sterilization"), water rinsing, and proper handling and storage. Surveys and reports indicate that not all health-care facilities dry their endoscopes after reprocessing. Endoscope drying can be easily, quickly, and inexpensively achieved by flushing the endoscope's internal channels, and wiping its external surfaces, with 70-90% ethyl or isopropyl alcohol, to facilitate drying after reprocessing, followed by compressed or forced air.

METHODS

The medical literature was reviewed to evaluate the importance of endoscope drying to the prevention of disease transmission. Several national and international endoscope-reprocessing and infection-control guidelines and a public health advisory were also reviewed and compared for consistency and to evaluate the emphasis each places on endoscope drying. If a guideline recommends endoscope drying, this study clarified whether this step is recommended after reprocessing throughout the day (i.e., between patient procedures), before storage, or both. These guidelines were also reviewed to determine whether any of them recommend reprocessing endoscopes before the first patient of the day.

RESULTS

This review identified several published reports and clinical studies that demonstrate the significant contribution of endoscope drying to the prevention of disease transmission. This review also identified significant differences and inconsistencies regarding the emphasis different published guidelines and a public health advisory place on endoscope drying. Some guidelines recommend drying the endoscope after completion of every reprocessing cycle, both throughout the day and before storage, while others deemphasize its importance and recommend endoscope drying only before storage, if at all. Instead of recommending endoscope drying before storage, some guidelines recommend reprocessing endoscopes before the first patient of the day.

DISCUSSION AND CONCLUSION

The finding that several guidelines are inconsistent with one another and that some are remiss and fail to recommend endoscope drying is of concern. Endoscope drying is as important to the prevention of nosocomial infection as cleaning and high-level disinfection (or "liquid sterilization"). Whereas wet or inadequately dried endoscopes pose an increased risk of contamination and have been associated with transmission of waterborne microorganisms and nosocomial infection, thoroughly dried (and properly cleaned and high-level disinfected) endoscopes have not been linked to nosocomial infection. Moreover, inconsistent guidelines can confuse reprocessing staff members and result in noncompliance, variations in the standard of care, and ineffective reprocessing. To minimize the risk of disease transmission and nosocomial infection, modification and revision of guidelines are recommended as required to be consistent with one another and to unconditionally recommend endoscope drying after completion of every reprocessing cycle, both between patient procedures and before storage, no matter the label claim of the LCS or disinfectant, the label claim of the automated reprocessing system, or the microbial quality of the rinse water. According to the medical literature, adoption of this recommendation may reduce the importance of not only monitoring the microbial quality of the rinse water, but also reprocessing endoscopes before the first patient of the day, both of which can be costly practices that a few guidelines recommend.

Current issues in endoscope reprocessing and infection control during gastrointestinal endoscopy

The purpose of this article is to review the evidence regarding transmission of infection during gastrointestinal endoscopy, factors important in endoscope reprocessing and infection control, areas to focus on to improve compliance, and recent developments and advances in the field.

Dear Los Angeles Times: the risk of disease transmission during gastrointestinal endoscopy

This is the second in a series of articles that review media reports investigating the risk of disease transmission associated with gastrointestinal flexible endoscopy. The first article in this series, "

COMMENTARY

Do Scopes Spread Sickness?'' was published in this journal in 1999 (Gastroenterology Nursing, 22(4), 179-180).

Endoscope reprocessing and repair costs

Endoscope reprocessing and repair are important factors in regard to patient safety, optimal endoscope function, and costs. Endoscope reprocessing requires high level disinfection. There are three steps in reprocessing; mechanical cleaning, disinfection, and that is followed by rinsing and drying. The most critical step is mechanical cleaning which results in a 10 (4) reduction in microbial contamination or bioburden. Improper cleaning can overwhelm high-level disinfection regardless of subsequent steps and is the most susceptible to error. Endoscopy costs are dependent on costs of instruments, cleaning costs, and repair costs. The average repair costs at our endoscopy unit remained stable for more than 4 years suggesting a durable life of use. Consideration of endoscope accessories use should consider potential damage to endoscope use, cost to process re-useable items, sterility, and consideration of recent legislation on reprocessing of single-use devices.

Application of environmental sampling to flexible endoscope reprocessing: the importance of monitoring the rinse water

The routine sampling of environmental surfaces within a healthcare facility is generally not recommended by the Centers for Disease Control and Prevention (CDC), the Association for the Advancement of Medical Instrumentation (AAMI), and several other healthcare organizations. There are a few circumstances, however, for which some organizations do recommend this practice. For instance, the CDC and the Association for Professionals in Infection Control and Epidemiology (APIC) recommend environmental sampling as clinically required during an outbreak investigation. The CDC and AAMI also recommend routine sampling of the rinse water used during hemodialyzer (but not endoscope) reprocessing. The rationale for this recommendation is based in part on reports of pyrogenic responses, patient infections, and bacteremia due to waterborne, gram-negative bacteria during hemodialysis. To determine whether the basis for this rationale might similarly apply to the rinse water used during endoscope reprocessing, the Food and Drug Administration's medical device reporting database, the endoscope reprocessing literature, and other sources were reviewed. The results of this review indicate that nosocomial outbreaks linked to endoscopes contaminated with gram-negative bacteria have been frequently reported. As a result, for several reasons, including to minimize the risk of patient infection due to gram-negative bacteria following endoscopy, this article recommends routine microbiologic sampling of the rinse water used during endoscope reprocessing.