Healthcare Hygiene magazine November 2019 | Page 16

level of microbial contamination; effective precleaning of
the endoscope; presence of biofilm; physical properties of
the object; concentration, temperature, pH, and exposure
time to the germicide; and drying after rinsing to avoid
diluting the disinfectant.
➋ Intermediate-level disinfection: the destruction of all
mycobacteria, vegetative bacteria, fungal spores, and some
nonlipid viruses, but not bacterial spores.
➌ Low-level disinfection: a process that can kill most
bacteria (except mycobacteria or bacterial spores), most
viruses (except some nonlipid viruses), and some fungi.
• “Sterilization is defined as the destruction or inactivation
of all microorganisms. The process is operationally defined
as a 12-log reduction of bacterial endospores.”
Lichtenstein and Alfa (2019) remind us that, “HLD of
endoscopes eliminates all viable microorganisms, but not
necessarily all bacterial spores. Although spores are more
resistant to HLD than other bacteria and viruses, they are likely
Q
& A
to be killed when endoscopes undergo thorough manual
cleaning. In addition, survival of small numbers of bacterial
spores with HLD is considered acceptable because the intact
mucosa of the GI tract is resistant to bacterial spore infection.
Endoscope sterilization, as opposed to HLD, is not required
for ‘standard’ GI endoscopy, as a reprocessing endpoint of
sterilization has not been demonstrated to further reduce
the risk of infectious pathogen transmission from endo-
scopes. Sterilization of endoscopes is indicated when they
are used as ‘critical’ medical devices, such as intraoperative
endoscopy when there is potential for contamination of
an open surgical field. In addition, individual institutional
policies may dictate sterilization of duodenoscopes and
linear endoscopic ultrasound instruments due to elevator
mechanisms that have been difficult to clean and eradicate
all bacterial contaminants with HLD alone.”
Achieving the levels of clean as defined by guidelines
and recommendations stakes some skill but it is possible.
Continued from page 15
• Brushes that are too stiff or have un-
protected tips, either of which can gouge
or scrape endoscope surfaces, thus creating
the perfect capture of organic soiling and
protective troughs for biofilm formation
• Failure to keep routine maintenance schedules
• Poor cleaning technique, including pushing the brush
straight down and pulling it straight out, then assuming
all lumen surfaces have been cleaned
• Failure to clean some of the channels completely
due to unfocused attention, or not studying the IFUs and
never being qualified for each endoscope type initially
• Assuming the AER will clean every endoscope
completely
• Not properly cleaning and disinfecting all parts of
the AER per their IFU
• Not using the correct high-level disinfectant, prepar-
ing it incorrectly, or not replacing it according to the IFU
• Not sterilizing the rinse bottle as frequently as
required and using the correct water specifications
• Not opening or closing various caps and valves
before cleaning
• Not rinsing with appropriate grade of water
• Not drying completely as quickly as possible to
prevent contamination with bacteria and allowing time
and a moist condition in which to multiply
• Placing in dirty area or cabinet after cleaning or dirt missed in cleaning is essential, together with a
standard operating procedure that schedules and confirms
those observations. I also believe it is essential to have a
monitoring system such as ATP, protein, and hemoglobin
(depending on the scope use) quantification to enable
routine real-time monitoring. For example, running one
or more of these evaluations immediately after cleaning,
enables staff to reprocess the endoscope right away.
Most of the procedural breaches are the result of poor
training and/or not conducting performance verification
assessments. However, shortage of staff and lack of
budget to purchase, lack of added time required, or
lack of knowledge on how critical it is to purchase and
use correctly the tools to monitor the condition and
cleanliness of our endoscopes. I believe a borescope
enabling the technician to see inside the lumen with
well-lighted magnification and take pictures of damage HHM: What else should sterile processing techs
know?
WT: Pre-cleaning at the point of use is so critical, I
believe the OR must be part of the education as well,
to understand how important the timing and quality
of the wipe-and-flush are in the prevention of future
post-surgical infections. Every OR nurse and surgery tech
should be required to spend at least one full day in the
device reprocessing department (from A to Z.).
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HHM: What’s the best way for institutions to
help their sterile processing techs become aware
of this danger and address it?
WT: Training on each endoscope type, followed by
a qualifying performance of the testing and periotic
retesting or observational assessments. I also believe
that understanding consequences via educational pre-
sentations help, but as much as understanding adverse
consequences, SPD staff need to realize they are some of
the most important staff members of the entire hospital
or ASC. They save lives!
HHM: Are the complicated manufacturers’ IFUs
somehow to blame here?
WT: Definitely. Some have up to 57 steps! Some are
written in engineering-level language rather than clear
step-by-step. Others do not spell out important consid-
erations such as water quality required, pictures, etc.
november 2019 • www.healthcarehygienemagazine.com