April 5, 2013 — Below, I respond to two questions about the reprocessing of gastrointestinal (GI) endoscopes:

  1. “It is an acceptable practice for a GI endoscopy unit to pre-clean the GI endoscope at bedside immediately following an endoscopic procedure performed near the end of the day, but sometimes due to limited staff availability, not more thoroughly clean and high-level disinfect the endoscope (using an automated reprocessor) until the next day?”; and
  2. “It is an acceptable practice for a GI endoscopy unit to initiate the automated reprocessing of the GI endoscope, but sometimes due to limited staff availability, allow the reprocessor’s cycle to complete (on its own) and the flexible endoscope to remain and be stored overnight, and not be removed from the reprocessor’s basin for reuse, until the next morning?”

Dr. Muscarella’s reply to Question #1: In response to the first question, the answer is No.

Published guidelines require that the flexible endoscope be reprocessed promptly after the procedure. As Dr. Muscarella clarifies in his associated article, “Delayed reprocessing of gastrointestinal endoscopes” (read it by <clicking here>), ‘endoscope reprocessing’ (at least of GI endoscopes) is defined as immediate bedside cleaning, or pre-cleaning (which may be referred to as phase 1), followed by prompt and thorough cleaning, high-level disinfection, and drying of the GI endoscope (which may be referred to as phase 2) for its reuse or storage.

That same article by Dr. Muscarella also provides a step-by-step set of instructions for pre-cleaning the endoscope at bedside.

On this topic of the risk of disease transmission associated with the improper reprocessing of GI endoscopes, please read Dr. Muscarella’s article by       <clicking here>.

If the endoscope were pre-cleaned at the end of Day 1, but were not to be thoroughly reprocessed (that is, cleaned, high-level disinfected, and dried) until the next day, on Day 2, then the practice would contravene guidelines and, due to the potential for patient fluids and materials to dry inside the endoscope’s internal channels (e.g., the GI endoscope’s auxiliary water channel), this quality deviation could pose an increased risk of patient-to-patient disease transmission and, if identified as a contributor to a post-endoscopic infection, potentially expose the GI endoscopy unit to legal risk.

On this topic of legal risk associated with improper reprocessing of GI endoscopes, please read Dr. Muscarella’s article “A legal case and verdict about improperly reprocessed GI endoscopes” by <clicking here>.

Another of Dr. Muscarella’s articles that is germane to this discussion — “Protocol for ‘prepping’ a GI endoscope prior to its delayed reprocessing” — provides a step-by-step protocol that may be suitable for preparing or “prepping” a soiled GI endoscope (or a comparable type of flexible endoscope or reusable medical instrument) in advance of its delayed reprocessing.

Dr. Muscarella’s reply to Question #2: Similarly, in response to the second question (see above), the answer again is No.

Published guidelines require that the flexible endoscope be stored properly after reprocessing (if not promptly reused on a patient), namely, that the GI endoscope be hung vertically in a dry, clean, well-ventilated environment or setting, with its valves removed – criteria that the idle storage of a GI endoscope in the basin of an automated reprocessor, of course, would not satisfy.

The particular concern would be of waterborne bacteria colonizing and proliferating in the GI endoscope’s internal channels, posing an increased  risk of such types of infections as Pseudomonas aeruginosa infection. The practice of improper drying and storage of flexible endoscopes has been linked to bacterial outbreaks with associated morbidity and mortality, especially following ERCP.

Read Dr. Muscarella guest editorial in Endoscopy entitled “Investigation and prevention of infectious outbreaks during endoscopic retrograde cholangiopancreatography” (or, ERCP) by <clicking here>.

Dr. Muscarella has written extensively on the proper storage of flexible endoscopes, to prevent disease transmission. One of his articles — which is entitled “An event-related paradigm applied to the storage of flexible endoscopes” and may be read by <clicking here> — provides several recommendations, and the reader is directed to its recommendation #2.

Also read Dr. Muscarella’s blog, “Infections of Pseudomonas aeruginosa linked to flexible endoscopes” by <clicking here>.

Article by: Lawrence F. Muscarella, Ph.D. (Infection Prevention Educator), posted on 4-5-2013; revised: 5-11-2013.

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