Sri Mandava Infection Control Managing Endoscopes Patient Safety Regulatory Compliance Visual inspection has emerged in recent years as an important quality assurance step during endoscope reprocessing. Updated guidelines from AAMI, AORN and SGNA have all included a visual inspection step during the disinfection process to ensure that scopes are being thoroughly prepared for the next patient.

All three standards organizations have come out in support of adding the visual inspection in order to get a next level verification that all residual soil is removed during reprocessing. These visual inspections, in addition to cleaning verification tests, act as a check on an organization’s cleaning process. If scopes are continuously failing the cleaning verification or visual inspections, the reprocessing process may not be rigorous enough. This article by Mary Ann Drosnock at Healthcare Purchasing News summarizes what to look out for during a visual inspection:

“What are the kinds of evidence you should look for before endoscopes proceed to high-level disinfection? According to the guidelines, the endoscope should be inspected visually for conditions that could affect the disinfection process such as cracks, corrosion, discoloration, retained debris, and poor fiber optic illumination. Other items to inspect for, as noted by AORN, are cleanliness, missing parts, clarity of lenses, integrity of seals and gaskets, moisture, physical or chemical damage, and function. The use of magnification and adequate lighting does help assist in the visual inspection process to identify these abnormalities. These are the common warning signs that the scope is in need of repair or additional processing.

Other warning signs that an item may not be ready to be disinfected or sterilized are peeling of adhesives, cracks in lenses, brush gouge/scrape marks at the distal tip, stretched out covers on the bending section, and soil around or under the control knobs. Essentially, compare the scope to a new one and identify what is different. Then, evaluate if this could be a significant issue that may impact the ability of the scope to be cleaned, disinfected, or sterilized and could this be a risk to the patient?

There are other more obscure warning signs that the endoscope may need more attention or that reprocessing procedures are not in a state of control. Things like moisture retained in the channel upon inspection with a borescope after disinfection would tell you that your drying processes are not adequate. Retained lint/fibers are also very commonly seen upon inspection with a borescope and would bring to light the possible practice that staff members are not using lint-free or low-linting clothes or sponges during reprocessing. Retained brush bristles would warrant investigating the condition of reusable brushes or the possible practice of reusing single-use brushes mistakenly. Internal channels that are heavily damaged by gouging or scraping may warrant taking a look at the physician practices with endoscope accessories, such as keeping the distal tip angulated while passing or removing a biopsy forceps.

Use of a borescope for inspection of internal channels of the endoscopes is an additional step that may be taken to engineer quality into an endoscope’s reprocessing program. Both ST911 and AORN endoscope guidelines do highlight the process within their document. For example, AORN states that “Internal channels of flexible endoscopes may be inspected using an endoscopic camera or borescope. [2: High Evidence] Endoscopic cameras and borescopes penetrate the lumen and allow for improved visual inspection. Certainly, inspection of the internal channels with a borescope is a quality-driven process and will help a facility to assess the condition of their endoscopes, the overall reprocessing procedures and potentially the drying process. The one issue that is often raised with inspection with borescopes is when to perform this process.

Many facilities inspect their scopes periodically after the disinfection process is complete and the scopes are in storage. If doing this, then the scope should be reprocessed again before use. By performing inspection at this stage in the process, a facility can assess their internal drying practices and clearly determine whether it is currently being performed adequately or not. According to SGNA, scopes must be completely dry prior to storage or should not be used on patients without being reprocessed again. Other facilities will inspect with a borescope after manual cleaning prior to disinfection or sterilization. Although this is an option, the scopes are highly contaminated at this point and completely wet internally. A complete drying procedure would need to be initiated after cleaning in order to inspect with the borescope. If not, all that will be seen is water, which is not helpful.

Therefore, to perform a visual inspection, at a minimum the unaided eye should be used to inspect the external surfaces of the endoscope after manual cleaning. Additionally, current standards and guidelines do call for the additional use of lighted magnification to be added to the process of visual inspection. The process of performing cleaning verification is also clearly warranted based upon the current standards and guidelines. Borescopic examination of internal channels is a newer process, but one that is recommended within AAMI ST911 and AORN endoscope guidelines.”

https://www.mobileaspects.com/the-importance-of-visualinspection- for-endoscope-reprocessing/

October 30, 2017

I recently completed a fascinating one-hour course offered by Ofstead & associates that discussed insoluble substances inside endoscope after use. Infant gas relief drops, Gas-X, Mylanta Gas and other products tha contain simethicone are inserted in the biopsy channel when there is trouble seeing due to bubbles or foam.

The problem for reprocessing endoscopes with simethicone is that it is insoluble in water, detergent and alcohol. Simethicone will actually repel water, making removal from biopsy or water channels very difficult. It is possible to remove the droplets of simethicone by locating the droplets and using swabs. The borescope can then be used to verify the removal of the substance.

The course also discusses how Tissue glue may also be found inside the channels of colonoscopes. If tissue glue is allowed to harden in the working channel it may not able to be removed. The working channel may become blocked and require repair of the instrument. I was also surprised to learn that the use of cooking spray has a lubricant inside working channels is another source of simethicone (silicone) residue. The oils residue can be cleaned using hot water and detergent the simethicone still remains a problem.

This was a very revealing course that exposes many of the issues faced when reprocessing endoscopes. It also reinforces the need to use a borescope to inspect the lumens and channels of endoscopes. I recommend that anyone involved in the reprocessing of endoscopes take the time to learn from this webinar.

Pasadena health officials said Wednesday that 16 patients were infected by dangerous bacteria from medical scopes at Huntington Hospital from January 2013 to August 2015, including 11 who have now died. Many of those patients were already severely ill, including some with cancer.

Health officials said that only one of the 11 death certificates listed the bacteria as the cause. It was not clear if infection was a factor in any of the other deaths. The hospital had previously said just three patients were infected in the outbreak that officials said was limited to the middle of 2015. The patient infections were detailed in the Pasadena Public Health Department’s investigation into the outbreak. The report blamed both the design of the scope and the hospital for lapses in infection control. For example, investigators discovered visible residues in the machines used to clean the scopes,according to the report released on Wednesday. Investigators also said the hospital had been using canned compressed air from Office Depot to dry the scopes – which is not recommended by the manufacturer or by cleaning guidelines.

Pasadena health officials said they had found no additional scope-related infections since the start of their investigation on Aug. 19. Dr. Paula Verrette, Huntington’s chief medical officer, said Wednesday the hospital has now changed its practices based on the findings and recommendations of health officials.“Patient safety remains our highest priority,” she said. Lawrence Muscarella, a medical safety consultant in Montgomeryville, Pa. who has been following the scope outbreaks, said the Pasadena case showed that many more patients may have been infected across the country than has been publicly reported.“This shows a total failure of the system, from top to bottom,” said Muscarella. Huntington hospital officials had confirmed last August that three patients were sickened the previous month but declined to say more about their condition. They later told Olympus Corp., the scope’s manufacturer, of at least three deaths, according to the company’s report tofederal regulators.When the regulatory reports were discovered, hospital officials said that they believed patient privacy laws prevented them from telling the public that the unnamed patients had died.

The investigation said that Huntington doctors had started doing their own review of possible infections in July after finding three patients sickened with drug-resistant Pseudomonas  aeruginosa. The hospital staff had identified as many as 35 cases of possible infections, which they had been evaluating before Pasadena officials arrived on Aug. 20 in an unannounced site investigation. The health officials concluded that 15 of these cases were linked to procedures the patients had with an Olympus scope. Then in March, hospital officials told the health department that they found an additional patient who was infected. That patient had a scope procedure in July 2013.The hospital found 13 other patients infected with the bacteria but determined they were not sickened by the scopes. Huntington doctors told health officials on May 23 that they were now notifying all patients who had been treated with the scopes since January 2013 about the possibility of infections.

Previously, the hospital had notified only those patients who had been treated between Jan.2015 and August 20, 2015. The duodenoscope is a long snake-like tube with a tiny camera on the tip that is inserted into a patient’s throat and upper gastrointestinal tract. It is used to treat cancer, gallstones and other problems in the bile or pancreatic ducts. In January, Olympus recalled one model of its reusable duodenoscopes because of the possibility that it could transfer bacteria between patients. That model was linked to two other Southern California outbreaks at UCLA Ronald Reagan Medical Center and Cedars Sinai Medical Center. Two of the reusable scopes suspected of causing the Pasadena outbreak had a different, older design from the one that Olympus recalled. The investigation said that tests had found the bacteria Pseudomonas aeruginosa on three of Huntington’s scopes. Investigators also found another kind of bacteria inside the washer used to clean the scopes.“This broad bacterial contamination,” the report said, “supports the hypothesis” that disinfection and maintenance “were insufficient to prevent the spread of infection.”In a visit on September 11, Pasadena officials found that the hospital had improved its cleaning of scopes, including doing “major maintenance” on the machines used to disinfect them. They said that Olympus specialists had been to the hospital multiple times to train the staff on proper disinfection procedures.

LA Times June 1, 2016

Melody Peterson

In an ominous sign for patient safety, 71% of reusable medical scopes deemed ready for use on patients tested positive for bacteria at three major U.S. hospitals, according to a new study. The paper, published recently in the American Journal of Infection Control, underscores the infection risk posed by commonly used endoscopes. It signals a lack of progress by manufacturers, hospitals and regulators in reducing contamination despite numerous reports of superbug outbreaks and patient deaths, experts say. “These results are pretty scary,” said Janet Haas, president of the Association for Professionals in Infection Control and Epidemiology. “These are very complicated pieces of equipment, and even when hospitals do everything right we still have a risk associated with these devices. None of us have the answer right now.” The study found problems in scopes used for colonoscopies, lung procedures, kidney stone removal and other routine operations. Researchers said the findings confirm earlier work showing that these issues aren’t simply confined to duodenoscopes, gastrointestinal devices tied to at least 35 deaths in the U.S. since 2013, including three at Ronald Reagan UCLA Medical Center. Scope-related infections also were reported in 2015 at Cedars-Sinai Medical Center in Los Angeles and Pasadena’s Huntington Hospital

The bacteria this latest study found weren’t superbugs, but researchers said there were potential pathogens that would put patients at high risk of infection. The study didn’t track whether the patients became sick from possible exposure. The study’s authors said the intricate design of many endoscopes continues to hinder effective cleaning and those problems are compounded when health care workers skip steps or ignore basic protocols in a rush to get scopes ready for the next patient. The study identified issues with colonoscopes, bronchoscopes, ureteroscopes and gastroscopes, among others. “Sadly, in the 10 years since we’ve been looking into the quality of endoscope reprocessing, we haven’t seen improvement in the field,” said Cori Ofstead, the study’s lead author and an epidemiologist in St. Paul, Minn., referring to how the devices are prepared for reuse. “If anything, the situation is worse because more people are having these minimally invasive procedures and physicians are doing more complicated procedures with endoscopes that, frankly, are not even clean,” Ofstead said. The rise of antibiotic-resistant superbugs such as CRE (carbapenem-resistant Enterobacteriaceae), which can be fatal in up to half of patients, has made addressing these problems more urgent. About 2 million Americans are sickened by drug-resistant bacteria each year and 23,000 die, according to the Centers for Disease Control and Prevention. “We’re not moving fast enough to a safer world of reusable medical devices,” Michael Drues, an industry consultant in Grafton, Mass., who advises device companies and regulators. “There is plenty of fault to go around on device companies, hospitals, clinicians, on basically everybody.” Despite the potential risks, medical experts caution patients not to cancel or postpone lifesaving procedures involving endoscopes since they often spare patients from the complications of more invasive surgeries. The Food and Drug Administration and Olympus Corp., a leading endoscope manufacturer in the U.S. and worldwide, both said they are reviewing the study. Last month, the FDA issued warning letters to Olympus and two other scope makers for failing to conduct real-world studies on whether healthcare facilities can effectively clean and disinfect their duodenoscopes. The FDA ordered the manufacturers to conduct those reviews in 2015 after several scoperelated outbreaks in Los Angeles, Seattle and Chicago made national headlines. Olympus spokesman Mark Miller said the Tokyo-based company intends to “meet the milestones set forth by the FDA. … Patient safety has always been and remains our highest priority.”

The latest study examined 45 endoscopes, with all but two manufactured by Olympus. The other two were Karl Storz models. Last year, researchers visited three hospitals, which weren’t named, and performed visual examinations and tests to detect fluid and contamination on reusable endoscopes marked ready for use on patients. One hospital met the current guidelines for cleaning and disinfecting scopes, while the other two committed numerous breaches in protocol. Nevertheless, 62% of the disinfected scopes at the top-performing hospital tested positive for bacteria, including potential pathogens. It was even worse at the other two—85 and 92%. The study painted a troubling picture at the two lower-performing hospitals, which were well aware researchers were watching. Among the safety issues: Hospital technicians wore the same gloves for handling soiled scopes fresh after a procedure and later, when they were disinfected and employees wiped down scopes with reused towels. Storage cabinets for scopes were visibly dirty and dripping wet scopes were hung up to dry, which is a known risk because bacteria thrive on the moisture left inside. The two hospitals also turned off a cleaning cycle on a commonly used “washing machine,” known as an automated endoscope reprocessor, to save time. “It was very disturbing to find such improper practices in big health systems, especially since these institutions were accredited and we assumed that meant everything would have been done properly,” said Ofstead, chief executive of the medical research firm Ofstead & Associates. Ofstead and her co-authors recommended moving faster toward sterilization of all medical scopes using gas or chemicals. That would be a step above the current requirements for highlevel disinfection, which involves manual scrubbing and automated washing. A shift to sterilization would likely require significant changes in equipment design and major investments by hospitals and clinics. In their current form, many endoscopes aren’t built to withstand repeated sterilization. Some also have long, narrow channels where blood, tissue and other debris can get trapped.

In some cases, disposable, single-use scopes are an option, and new products are starting to gain acceptance. In other instances, certain parts of a scope might be disposable or removable to aid cleaning. The Joint Commission, the nation’s largest accrediting body, issued a safety alert last year about disinfection and sterilization of medical devices in response to a growing rate of noncompliance. In 2016, the accreditor cited 60% of its hospitals for noncompliance and 74% of all “immediate threat to life” citations from surveyors related to improperly sterilized or disinfected equipment. Michelle Alfa, a professor in the medical microbiology department at the University of Manitoba, said accreditors may need to conduct more frequent inspections, and endoscopy labs should be shut down “if they don’t get their act together. These results are totally unacceptable.”

This story originally appeared in Kaiser Health News. Kaiser Health News, a not-for-profit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation. An edited version of this story can also be found in Modern Healthcare’s April 30 print edition

AN OUTBREAK HAS BEEN TRACED TO A CONTAMINATED endoscope at Hospital A.” “Several patients were notified that a contaminated flexible endoscope may have been used for their endoscopy procedures at Clinic B.” Headlines like these are becoming the internet to find information regarding incidents where contaminated (unsafe) endoscopes have been used in patient procedures. Several of these situations have been reported in the news media. The Centers for Disease Control and Prevention (CDC) tracks endoscope outbreaks. The US Food and Drug Administration (FDA) also monitors issues associated with flexible endoscopes.

Contaminated flexible endoscopes pose a significant risk to patients. Bacteria can be transmitted from patient to patient, and other sources of contamination may cause infection as well. Biofilm creates a matrix where bacteria are protected so they may grow. In some cases, multi-drug-resistant microorganisms may infect a patient. Those microorganisms are resistant to current medications and may be life threatening to patients. The responsibility for cleaning rests with endoscope reprocessing technicians. Knowledge, training, access to the right tools, and attention to detail are required to make an endoscope safe for patient use.

OBJECTIVE 1: REVIEW THE BASIC CONFIGURATION OF FLEXIBLE ENDOSCOPES
Successful cleaning of a flexible endoscope does not happen by accident. The cleaning process begins with understanding the complexity of the device being cleaned. At first glance, a flexible endoscope looks like a simple device; however, closer inspection proves that to be incorrect. Flexible endoscopes are designed to perform a variety of functions, and each function requires a special component of the endoscope. Each flexible endoscope has a control mechanism that allows the endoscope to be flexed up and down and from side to side during use. This function enables the physician to visualize structures and move the endoscope to improve access during the procedure. Light guides project light through the endoscope and objective lenses enable visualization.
In some endoscopes, channels provide air, water and suction. A biopsy channel allows an instrument to be passed through the endoscope. Each of those functions requires intricate interior design of the device, and that complex design complicates the cleaning process. In addition to a complex design, endoscope channels cannot be visualized with the naked eye, so technicians are challenged to clean areas they cannot see. The distal tip of an endoscope indicates its complexity. Each channel within the endoscope serves a function and it is critical to the overall function of the endoscope. Technicians must clean all areas that become soiled during use and they must do so with little to no ability to see the channels they are cleaning. Figure 2 provides an illustration of the complex interior design of a flexible endoscope.

FIGURE 1: The complexity of the interior of a flexible endoscope is illustrated in the distal tip. Each function represented in the distal tip provides a glimpse of the complexity of the interior of the endoscope. Note: Not all endoscopes are alike. Distal tip and interior configurations vary with the intended function of the endoscope.

OBJECTIVE 2: IDENTIFY CHALLENGES TO CLEANING FLEXIBLE ENDOSCOPES
In addition to their complex configuration, there are other factors that create cleaning challenges when reprocessing flexible endoscopes. The manufacturer’s instructions for use (IFU) must be followed exactly as they are written. When cleaning steps are skipped or when they are not performed for the correct amount of time or with the correct cleaning tools, cleaning errors also occur. This is particularly challenging because all endoscopes require multi-step cleaning. Some flexible endoscopes have over 100 steps in their cleaning process. The manufacturer’s IFU must be readily available and followed to reduce the risk of cleaning errors. The cleaning process can also fail if soil is allowed to remain on the endoscope after its use. When soiled endoscopes are not immediately cleaned, soil may dry, thereby, making the endoscope more difficult to clean. Prolonged exposure
to soil and moisture after use can also enable biofilm to form. Biofilm is a collection of microorganisms that attach to surfaces and each other to form a colony; that colony produces a protective gel that is very difficult for detergents and disinfectants to penetrate. Biofilm in a flexible endoscope is very difficult to remove and poses a danger to patients. All flexible endoscopes should be reprocessed as soon as possible after use to reduce the risk of dried soil and biofilm formation. Some flexible endoscope manufacturers require special cleaning processes (called delayed reprocessing procedures) to be enacted for endoscopes that sit for an hour or longer after they are used. It is important to check the IFU to determine cleaning time restrictions. Having access to the proper tools is another critical component of endoscope cleaning. Cleaning can fail if brushes of the wrong size are used. Brushes that are too small will not make appropriate contact with channel walls and openings. Brushes that are too large may impede the cleaning process. Cleaning solutions and other tools used for flushing and rinsing must also be available and used according to each manufacturer’s IFU. Training also plays a role in the success of the cleaning process. As previously stated, proper cleaning is a multi-step process that must be performed exactly as outlined in the IFU. Endoscope reprocessing technicians must also understand the chemicals and tools used in the cleaning process and must apply that knowledge correctly for every endoscope. No one should reprocess a flexible endoscope alone unless they have had training and have completed a competency evaluation. Time is a significant factor in successful endoscope cleaning. In many cases, endoscopes must be reprocessed and returned to the user department under tight timelines. Pressure is sometimes exerted to move the endoscope through the process quickly. When those timelines are unrealistic and demands for turnaround are forceful, technicians may feel tempted to skip steps or cut corners in the cleaning process; this can lead to unsafe endoscopes being released for use. In some cases, the cleaning process may be successful, but the endoscope may become recontaminated after cleaning; this may occur due to endoscope mishandling (e.g., handling a clean endoscope while wearing soiled PPE or placing an endoscope on an unclean surface after cleaning). Moisture is another danger for endoscope contamination. If a flexible endoscope is not completely dried, any moisture that remains in the endoscope’s channels creates an environment where bacteria can grow and multiply. Bacteria multiply quickly and as they do, the level of contamination of an endoscope grows as well. Figure 3 provides an example of how quickly bacteria can grow. When an endoscope containing moisture is stored, its dark, wet lumens and crevices provide a receptive place for microorganisms to multiply.

FIGURE 3: When the endoscope is removed from the storage cabinet and placed into service, it is contaminated and poses a threat to patient safety.

OBJECTIVE 3: DISCUSS THE PREVALENCE OF DIRTY FLEXIBLE ENDOSCOPES
Even if dirty endoscopes were a rare occurrence in a healthcare facility, their occurrence would still be unacceptable. Unfortunately, incidents involving dirty endoscopes are all too common. In its 2018 Top 10 List of Health Technology Hazards, ECRI Institute cited endoscope reprocessing failures and improper cleaning as the number 2 and number 5 patient risks, respectively. A study conducted by Ofstead and Associates revealed that 99% of the time, one or more reprocessing steps were skipped or completed incorrectly. Multiple steps were skipped 45% of the time. Every endoscope reprocessing area should audit their cleaning processes to help ensure each step is being performed exactly as stated in the device manufacturer’s IFU. Dirty endoscopes pose a significant risk to patients. There is a misconception that a dirty endoscope can be made safe by a high-level disinfection or sterilization process. It is important to remember that soil and bacteria remaining in an endoscope will not be eradicated by disinfection or sterilization processes. Those processes cannot compensate for inadequate cleaning. Put simply, any endoscope that is not clean will remain dirty and dangerous when used on the next patient. Each facility and technician must evaluate practices and take necessary steps to reduce the incidence of dirty flexible endoscopes. Dirty flexible endoscopes are a patient safety issue and their elimination should be prioritized.

CONCLUSION
Whenever a dirty endoscope is used in a procedure, the patient is put at risk. Several factors have an impact on the process of making a flexible endoscope safe for patient use; this includes the device’s configuration, complex cleaning instructions, and human factors. Dirty endoscopes put patients at risk of infection. Training, proper cleaning tools and meticulous attention to detail can reduce that risk.

RESOURCES
International Association of Healthcare Central Service Materiel Management. 2017. Endoscope Reprocessing Manual, First Edition. Ofstead C, et al. Re-evaluating Endoscopy- associated Infection Risk Estimates & their Implication. American Journal of Infection Control. 41 (2013), pp. 734-6. 2. Ofstead C, et al. Endoscope Reprocessing Methods: a Prospective study on the Impact of Human Factors and automation. Gastroenterology Nursing, July/Aug 2010. ECRI Institute. 2018 Top 10 Health Technology Hazards. https://www.ecri.org/Resources/Whitepapers_and_reports/Haz_18.pdf Association for the Advancement of Medical Instrumentation. ANSI/AAMI ST91:2015. Flexible and semi-rigid endoscope processing in health care facilities.

Supervisory Continuing Education (SCE) lessons provide members with ongoing education focusing on supervisory or management issues. These lessons are designed for CER re-certification, but can be of value to any CRCST in a management or supervisory role. Earn Continuing Education Credits: Online: Visit www.iahcsmm.org for online grading at a nominal fee. By mail: Mailed submissions to IAHCSMM will not be graded and will not be granted a point value (paper/pencil grading of the SCE Lesson Plans is not available through IAHCSMM or Purdue Univer-sity; IAHCSMM accepts only online subscriptions). Scoring: Each online quiz with a passing score of 70% or higher is worth two points (2 contact hours) toward your CER re-certification (6 points) or CRCST re-certification (12 points). More information: IAHCSMM provides online grading service for any of the Lesson Plan varie-ties. Purdue University provides grading services solely for CRCST and CIS lessons.

Dirty endoscopes are a real issue with all hospitals and surgery centers. 71% of reusable endoscopes labeled as “clean” tested positive for bacteria at three major U.S. hospitals, according to a recent study.

Endoscopes are very complicated equipment, and even when sterile process departments clean dirty endoscopes correctly, there is still a risk associated with these devices.

One study found problems in different types of endoscopes. Dirty duodenscopes are responsible for at least 35 deaths, and researchers have found that different types of endoscopes are related to infections.

The complicated design of many endoscopes makes effective cleaning difficult. Those problems increase when sterile processing skip steps or ignores the necessary procedures to have endoscopes ready for the next patient. A study identified issues with colonoscopes, bronchoscopes, ureteroscopes, gastroscopes, and other endoscopes.

Antibiotic-resistant superbugs such as CRE (carbapenem-resistant Enterobacteriaceae), which can be fatal in up to half of patients, has made addressing dirty endoscopes more urgent. Two million Americans are sickened by drug-resistant bacteria each year, and 23,000 dies, according to the Centers for Disease Control and Prevention.

A recent study examined 45 endoscopes and did a visual inspection to detect fluid and contamination on reusable endoscopes. They were marked ready for use on patients. 92% of the disinfected endoscopes tested positive for bacteria, including potential pathogens at some hospitals. These dirty endoscopes could potentially infect healthy patients.

Endoscopes have long, narrow channels where blood, tissue, and other debris can get trapped. The only way to see inside narrow lumens and channels is with a borescope. If a sterile processing department does not have a borescope, it is impossible to view debris and contamination.

Today, numerous agencies recommend visual inspection of endoscopes and other medical devices. Examining the exterior with magnified light is recommended; however, a borescope visually inspects small channels and lumens. Without a borescope, sterile processing departments cannot say they are complying with industry recommendations to prevent dirty endoscopes labeled as “clean”.

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I recently completed a fascinating one-hour course offered by Ofstead & associates that discussed insoluble substances inside endoscope after use. Infant gas relief drops, Gas-X, Mylanta Gas and other products that contain simethicone are inserted in the biopsy channel when there is trouble seeing due to bubbles or foam. These products contain silicone or simethicone which is an anti foaming agent. The use of these products aid seeing when foaming interferes with a colonoscopy.

The problem for reprocessing endoscopes with simethicone is that it is insoluble in water, detergent and alcohol. Simethicone will actually repel water, making removal from biopsy or water channels very difficult. This represents a very real problem when reprocessing endoscopes because any remaining silicone is a potential contaminant that can infect subsequent patients. It is possible to remove the droplets of simethicone by locating the droplets and using swabs. The borescope can then be used to verify the removal of the substance.

The course also discusses how Tissue glue may also be found inside the channels of colonoscopes. If tissue glue is allowed to harden in the working channel it may not able to be removed. The working channel may become blocked and require repair of the instrument. I was also surprised to learn that the use of cooking spray has a lubricant inside working channels is another source of simethicone (silicone) residue. The oils residue can be cleaned using hot water and detergent the simethicone still remains a problem.

This was a very revealing course that exposes many of the issues faced when reprocessing endoscopes. It also reinforces the need to use a borescope to inspect the lumens and channels of endoscopes. I recommend that anyone involved in the reprocessing of endoscopes take the time to learn from this webinar.

All endoscope lumens need to be visually inspected after cleaning to locate residual material that remains. The fact that simethicone is found inside endoscope lumens after cleaning makes a strong case for a visual inspection program center around the use of borescopes. Visually inspecting endoscope lumens after cleaning can prevent future infections. If any residual material remains in an endoscope lumen swabs should be used to remove the material. Brushes and water will typically not aid in removing simethicone. This process should be repeated until the lumen can verified to be clean with the aid of a borescope.