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Infection
Control -
Recommended Guidelines in the Endoscopy
Setting
Terminology
Clean
- Visibly free from debris
Endoscope -Flexible
- Flexible fiberoptic or video endoscope used in the examination of the
hollow viscera (i.e. colonoscope, gastroscope, duodenoscope, sigmoidoscope,
bronchoscope).
High -Level Disinfectant
- A liquid chemical germicide which is capable of destroying all microbial
life including high numbers of bacterial endospores but is used under
conditions where it achieves the destruction of all vegetative bacteria,
viruses and fungi but not necessarily all bacterial endospores.
Patient - Ready Endoscope
- An endoscope rendered clean after being subjected to a validated cleaning
procedure subjected minimally to a high level disinfection process and
rinsed so that it does not contain residual chemicals in amounts that can be
harmful to humans.
Alcohol
- 70% isopropyl or ethyl
alcohol
Air
- Airflow provided by a pump or
compressor.
Detergent
- Low-sudsing enzymatic formulations recommended by the manufacturer of the
endoscope.
Water
- Clean potable water or potable water that has been filtered by passage
through a .2um filter of otherwise treated by a method documented to improve
the microbiological quality of the water.
Background
Attention must be given to the
implementation of infection control standards. Contaminated endoscopes and
accessories are potential sources of infection for both patients and
personnel. Strict guidelines are needed to standardize the
cleaning/disinfecting/sterilization processes. These guidelines are intended
to assist institutions and Endoscopy units in the development of policies
for their specific needs.
Recommendations for Safety of Personnel
Safety is of the utmost
importance and should be in the forefront of each employee's mind.
Consistent practice must be maintained to prevent the spread of disease and
to protect from the dangers of the chemicals used in the cleaning and high
level disinfection of endoscopes. Universal precautions must be
practised
at all times.
- All
personnel should be immunized against Hepatitis B.
- Health
care workers who have respiratory problems (i.e. asthma) should be
assessed by Occupational Health prior to working with chemical germicides.
- Eye
protection and moisture resistant masks or face shields should be worn to
prevent contact with splashes during the cleaning procedure and
disinfection/sterilization process.
- Moisture
resistant gowns should be worn to prevent contamination of personnel due
to splashes of blood or other body fluids or injury due to chemical
disinfectant/sterilant contact. The changing of gowns is recommended
between procedures.
- Protective
apparel (gown and mask) should be removed when leaving the procedure room
and cleaning room.
- Gloves
should be worn for handling and cleaning of dirty equipment as well as for
any potential contact with blood or body fluids. Chemical resistant gloves
(nitrile) are recommended when handling disinfectant solutions.
- All
needles and sharps are to be appropriately disposed of in puncture
resistant containers at their point of use. Do not recap needles.
-
Fingernails should be kept short to prevent the puncturing of gloves.
Jewelry should not be worn on the hands because it harbors microorganisms
and may puncture gloves.
- Meticulous
hand washing should be done between patient contact, after glove removal
and when entering or leaving the Endoscopy area. If hands and other skin
surfaces are contaminated with blood or body fluids, wash immediately.
- Health
care workers who have exudative lesions or weeping dermatitis should
refrain from all direct patient care and from handling patient care
equipment until the condition resolves.
Recommendations for Endoscopes
Refer to the manufacturer's
instructions for cleaning and disinfecting each particular endoscope:
Scrupulous cleaning and disinfection after each patient use must be
completed to prevent the spread of infection. Only trained personnel will
perform this procedure.
Inspection
At all
stages of handling there should be inspection of the endoscope for damage.
Leakage
testing of the endoscope should be done each time before the cleaning
process starts.
Ensure
immersion cap is placed on all videoscopes.
If damage is detected or
bubbling occurs, ensure the pressure is maintained through the leakage
tester and proceed to carry out a thorough external cleaning and cleaning of
the internal channels. Follow your service provider's instructions
concerning disinfection of a damaged fiberscope. However, with proper
maintenance of internal pressure, manual disinfection of the scope in many
cases can be achieved. Send to the repair service immediately. If the scope
cannot be cleaned prior to transport, ensure that it is clearly labeled
'contaminated'.
Cleaning
Meticulous manual cleaning is
the most important step in the cleaning process. It is imperative that all
channels, removable parts and all
immersible
parts of the endoscope be
cleaned.
Wipe the outer surface with
enzymatic soaked gauze immediately after removal of the endoscope from the
patient. Using the air/water channel valve, flush the air/water channel
with water from the water bottle. Transport the scope to the cleaning area.
- If unable
to initiate the manual cleaning process immediately, the endoscope may be
flushed and then soaked with enzymatic solution.
- Leakage
test the scope following the manufacturer's instructions.
- Fully
immerse the scope in a solution with an enzymatic cleaner to prevent the
drying of secretions. Brush all channels to remove the organic material
and decrease the number of organisms present. Ensure that access to the
air/water/CO2 channel is attained, as these channels are very difficult
to clean.
- Ensure the
outer surface of the scope is thoroughly cleaned. Use of a soft bristle
toothbrush to clean the lens end is acceptable.
- All
channels must be brushed and irrigated to remove particulate matter. A
channel irrigator should be used to facilitate complete cleaning of all
channels.
- Rinse all
the channels and the endoscope thoroughly with water following the
cleaning process to remove the residual of the enzymatic agent.
- Remove all
excess water from the channels by injecting air via the all channel
irrigator to decrease the possibility of dilution of the disinfectant
solution.
- Clean all
non-immersible parts with a hospital recommended surface disinfectant.
- Non-immersible
endoscopes should be replaced because they are very difficult to clean and
disinfect.
Sterilization and
Disinfection
When deciding whether to
sterilize or disinfect the endoscope, it is important to refer to the
following classifications;
-
Critical devices are those that enter sterile tissue: the vascular system
or body space (i.e. biopsy forceps, polyp snares and surgical
instruments).
-
Semi-critical devices (i.e. laryngoscopes, endoscopes) come into contact
with mucous membranes or non-intact skin during use and should at least
receive high -level disinfection (defined as the inactivation of all
micro-organisms with the exception of bacterial endospores).
-
Non-critical devices (i.e. blood pressure cuffs, bedpans) come into
contact with intact skin.
Endoscopes
that come into contact with mucous membranes are classified as semi-critical
items.
Endoscopes
that enter sterile body cavities are classified as critical items.
- High level
disinfection of the endoscope internally and externally must be performed
after scrupulous mechanical cleaning has been completed. All processes
will be rendered ineffective if any organic material or moisture is
present on or in the endoscope.
- Chemical
agents registered with Canada Health and Welfare, as sterilant/
disinfectants are appropriate for high level disinfections. To ensure
efficacy, the manufacturer's instructions regarding use of disinfectant
must be adhered to.
- All
internal and external surfaces and channels must be in contact with the
disinfecting agent for not less than 20 minutes.
-
Disinfectant agents must be chosen carefully and must be used according to
the manufacturer's instructions including monitoring chemical
concentrations. Effective use-life is more dependent on frequency of use
rather than on a predetermined time or duration of use.
- Ethylene
Oxide (ETO) gas sterilization requires an extended time to complete the
sterilizing and aeration process. This may not always be practical.
- The
Peracetic Acid based automated system sterilizes immersible instruments
and rinses them with sterile water. Contact of all external and internal
surfaces with the sterilant must occur. Check with the manufacturer's
instructions regarding the cleaning of the elevator channel of the
duodenoscope.
- Hydrogen
Peroxide (H202) is acceptable for endoscopic reprocessing although it can
damage the external surfaces of the insertion tube and corrodes copper,
zinc and brass.
Rinsing
To remove all traces of the
disinfectant, adequate rinsing must follow the disinfection process. Any
residual chemical can cause toxic effects in a patient if it is transmitted
during the next endoscopic procedure.
The use of sterile water for
rinsing is recommended. If tap water is used, follow with 70% alcohol rinse
and dry with compressed air.
Drying
Air drying by the use of forced
air should be done after disinfection and before storage.
Prior to storage, facilitate
drying of the endoscope by flushing all channels with a 70% isopropyl
alcohol followed by forced air. Dry the insertion tube completely. Moist
environments are conducive to bacterial growth.
Channel valves should remain
out of scopes at the time of storage to facilitate the drying of channels.
Storage
Endoscopes should be stored
hanging vertically in a well-ventilated area in a manner that prevents
recontamination or damage. They should not be coiled and stored in their
cases.
Wipe down the storage cupboard
with disinfectant solution weekly.
Documentation
Results of disinfectant
solution testing should be documented. Institutional policy may require
documentation of disinfection cycles.
Culturing
Culturing requires very precise
techniques done in close consultation with an infection control department.
Institutional policy may dictate when and how culturing of scopes should be
carried out.
Special Considerations
Sterilization or high level
disinfection should be used as directed by institutional policy. Diagnosed
or suspected infection, including Hepatitis B, VRE, MRSA or HIV is not a
contraindication for endoscopy. It is not recommended to have instruments
dedicated for use with infected patients.
Recommendations for
Accessories
Non-disposable accessories
require meticulous manual cleaning and disinfection or sterilization after
each use according to manufacturer's guidelines and as directed by
institutional policy.
Cleaning Brushes should be
disposable or thoroughly cleaned and receive high-level disinfections after
each use.
Biopsy Forceps
Meticulous manual cleaning with
a brush and an enzymatic agent is required as soon as possible after the
procedure.
Ultrasonic cleaning is
recommended to remove debris that hand cleaning cannot.
Biopsy forceps break the
mucosal barrier. Therefore they are classified as critical instruments and
require sterilization.
The only method that will
effectively penetrate the metal coils of the spring-like structure and any
residual organic material is steam under pressure. Chemical sterilization
does not completely penetrate the coils and therefore is not effective.
Cleaning Brushes
The cleaning brushes should be
disposable or thoroughly cleaned and high level disinfected after each use.
Water Bottle
According to manufacturer's
instructions, sterilize or high level disinfect the water bottle and its
connecting tubing at least daily.
For endoscopic irrigation, fill
the bottle with sterile water.
Each ERCP procedure requires a
fresh sterile bottle with sterile water. Pseudomonas aeruginosa colonization
of equipment has been associated with patient infection following ERCP.
Other Accessories
Clean all non-disposable
accessories (i.e. polyp snares, tripods and foreign body forceps)
meticulously with an enzymatic agent followed by rinsing thoroughly with
water. Use the ultrasonic cleaner prior to steam autoclave.
Consult the manufacturer if
steam sterilization is not applicable.
Critical accessories (i.e.
sclerotherapy needles, electrocautery probes and hot biopsy forceps) should
be sterilized or discarded after each use.
Medical Equipment
Keep all non-critical equipment
(i.e. teaching heads, light sources, cameras) visibly clean with soap and
water or recommended institutional disinfectant.
If significantly soiled, use an
intermediate disinfectant after cleaning.
Recommendations for
Environment
General Cleaning
For general wipe-down of
equipment such as procedure carts, stretchers, sinks, etc. after each use,
an EPA registered housekeeping product is recommended.
Spills
In keeping
with Universal Precautions:
Disinfectant spills should be
handled by consulting the solution MSDS (Material Safety Data Sheet) WHMIS
Guidelines.
Waste
Minimal
handling of all medical waste should be encouraged.
The storage and disposal of
waste should be handled according to institutional policy and provincial and
federal guidelines.
Processing Area
Patient care areas should be
separate from cleaning/ disinfection areas.
Clean and dirty areas should be
separate with proper plumbing and drains. Adequate storage space should be
provided.
The use of covered containers
and proper ventilation to remove toxic vapors is essential.
Periodic air quality monitoring
of glutaraldehyde levels should be performed.
Automated Washers/
Disinfectants
Endoscopy unit cleaning/
disinfecting process may be standardized by the use of scope washer/
disinfectants. This equipment may be useful in circulating germicides,
containing vapors and decreasing exposure of personnel to contaminated
equipment and disinfectants.
Meticulous manual cleaning must
precede the use of any automated system as previously described.
Clean all non-immersible parts
of the endoscope with hospital recommended surface disinfectant.
The following capabilities must
be present in any washer/ disinfectant:
- Enzymatic
and/or disinfectant should be circulated through all channels at equal
pressure without trapping air.
- Washing
and disinfecting cycles should be followed by thorough rinsing cycles
followed by forced air to remove the used solution.
-
Disinfectant should not be diluted with wash or rinse water.
- Routine
disinfection of the washer/disinfectant according to the manufacturer's
recommendations and institutional policy must be done.
Other considerations:
- A channel
irrigator may miss a blockage of one channel.
- When used
to disinfect duodenoscopes, ensure that the channel for the elevator is
cleaned and disinfected as part of the processing cycle or it may require
manual processing.
- A forced
air-drying cycle or air-drying should be completed by hand after the final
rinse.
- If
unsterile water is used in the final rinse following the disinfection
cycle all endoscope channels must be flushed with 70% alcohol and dried
with air.
-
Colonization of bacteria may be caused by residual water remaining in the
water hoses and reservoirs. This could lead to contamination during
subsequent instrument processing.
Disclaimer
The Canadian Society
of Gastroenterology Nurses and Associates
assumes no responsibility for the practices or recommendations of any member
or other practitioner or for the policies and practices of any Endoscopy
unit.
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