CORRECT ENDOSCOPE REPROCESSING Christina Bradley Laboratory Manager Hospital Infection Research Laboratory Queen Elizabeth Hospital Birmingham HIRL Birmingham 1
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 HIRL Birmingham
Transmission of infection by flexible gastrointestinal 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) ERCP Endoscopic Retrograde Cholangio Pancreaticography UPPER GASTROINTESTINAL ENDOSCOPY 23 Inapprpopriate cleaning and disinfection povidone iodine, cetrimide Contaminated AER Incorrect connectors Failure to irrigate all channels Rinsing with tap water Contaminated water bottle 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 HIRL Birmingham 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
HIRL Birmingham 4
DECONTAMINATION OF FLEXIBLE ENDOSCOPES Meticulous cleaning Proper immersion in disinfectant Thorough rinsing after disinfection Endoscope Washer Disinfectors are the preferred option HIRL Birmingham 5
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 HIRL Birmingham
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 HIRL Birmingham
ENDOSCOPE CHANNELS HIRL Birmingham
DECONTAMINATION STAGES Pre clean at patient bed side Leak test Manual clean Endoscope Washer Disinfector Storage HIRL Birmingham
HIRL Birmingham CLEANING
PRE CLEANING At point of use Air/water channel External surfaces Suction channel Manufacturers instructions are essential HIRL Birmingham
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 HIRL Birmingham
HIRL Birmingham DISINFECTANTS
ENDOSCOPE DISINFECTANTS Glutaraldehyde Peracetic acid Chlorine dioxide Superoxidised water OPA Etc, etc. HIRL Birmingham 14
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 HIRL Birmingham 15
CHANNEL IRRIGATION DEVICES HIRL Birmingham 16
HIRL Birmingham 17
ENDOSCOPE DECONTAMINATION : POTENTIAL PROBLEMS Disinfectant Spectrum of activity Over use Water quality Bacterial contamination Chemical contamination Training Accessories e.g. water bottle, biopsy forceps HIRL Birmingham 18
HIRL Birmingham 19
HIRL Birmingham 20
BACTERIA FREE WATER Cystoscopes Bronchoscopes ERCP Potential for infection and/or misdiagnosis of infection HIRL Birmingham 21
HIRL Birmingham 22
ENDOSCOPE WASHER DISINFECTORS The WD440 machines: Single chamber Twin chamber (independent operated) HIRL Birmingham 23
ENDOSCOPE WASHER DISINFECTORS : PROBLEMS Disinfectant concentration Machine contamination Water quality Maintenance Validation HIRL Birmingham
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) HIRL Birmingham 25
TRANSPORTATION Protection of endoscopes and the environment from contamination and/or possible damage Separation of dirty and clean endoscopes HIRL Birmingham
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 HIRL Birmingham
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 HIRL Birmingham
STAFF TRAINING HIRL Birmingham 29
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 HIRL Birmingham 30
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 HIRL Birmingham
THANK YOU FOR LISTENING HIRL Birmingham 32