This series of self-study lessons on Central Service topics was developed by the International Association of Healthcare Central Service Materiel Management (IAHCSMM). The lessons are administered by Purdue University’s Continuing Education Division.
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2. Review handling techniques to prevent scope damage and cleaning errors
3. Explain basic procedures to process flexible scopes
4. Present suggested protocols to care for flexible scopes
Flexible endoscopes (scopes) are among the most expensive and difficult-to-maintain medical devices reprocessed by Central Sterile Supply Department (CSSD) employees. They allow physicians to visually observe body organs and passages, and diagnose illnesses and treat medical conditions. Scopes have been used for many years and procedures for handling, processing and caring for them have always been challenging. However, failure to properly do so can have
life-threatening consequences for patients. This lesson addresses these challenges.
Major components of flexible scopes are:
Universal (umbilical) cord. This element connects into the light source and scope processor, and plugs into the scope’s light source generator and image processor. The cord carries and receives information, electrical power and, depending upon scope type, air, suction and water. Note: Air inflates organs such as the bowel to allow viewing of structures. Suction removes fluid to aid in visualization and obtaining of specimens. Water flushes the scope’s distal end lens to help with visualization and irrigation of tissue. The light source supplies light to the distal end tip and permits an image to be observed.
Control section. This component contains the control levers, turn knobs, eye piece for visual scopes and/or the head for non-visual scopes, the instrument and biopsy channels, and the suction air/water control valves. It controls the angulations of the distal bending rubber and assists the operator to maneuver the scope to the body area being examined.
Insertion (working) tube: This is under the operator’s direct control and provides an extension of his/her eyes and hands.
It is inserted into an organ or body cavity and contains the distal end of the scope with lens and the bending rubber with control wires.
It also houses the light carrier and instrumentation channel, water, air and/or suction exit ports. The insertion tube is long and flexible to allow passage into convoluted areas.
Each of the scope’s major components is necessary to provide a clear, enlarged visual view of the pathology for the operator and surgical team. If it is damaged, non-operational, and/or not adequately processed, the ability to render safe and effective care will be compromised. CSSD personnel must be familiar with a scope’s operation and use to understand how to properly maintain it. This requires initial and ongoing instruction about safe use and handling.
Original equipment manufacturers (OEMs) can be requested to provide “hands-on” inservice training, and their operators’ manuals contain detailed handling, processing, and care information. They may also offer video-taped programs and other training resources to help CSSD personnel learn how to properly handle and maintain their scopes. These should be used to help prevent cleaning and reprocessing errors that can damage scopes, lead to expensive repairs, and cause scopes to be unavailable when needed.
Scopes should never be stored in-between use in their original shipping container because foam in the container could permit colonization of pathogens (disease-causing organisms) and lead to the scope’s cross-contamination
Instead, scopes should be stored vertically (upright) in an enclosed cabinet using a specially-designed scope holding device to prevent insertion tube kinks. Do not use commercial-type tool hangers because they may cause pressure points that puncture and tear the scopes’ outer coverings.
Scope storage cabinets should be temperature- and humidity-controlled, with adequate space between the scopes to promote air circulation that facilitates drying. Control buttons/valves and or biopsy ports should be detached to promote drying and drainage of residual moisture in the channels. Control and port items should be stored in a clean, dry environment, and separated to allow for easy selection, when needed. When the scope is not in the storage cabinet, ensure that the distal tip does not swing freely and strike a hard surface. If stored for an extended period, scopes should be reprocessed to ensure they continue to be free of bacteria.
Objective 3: Explain basic procedures to process flexible scopes
The pre-cleaning of flexible scopes begins in the surgical suite and involves careful compliance with the manufacturer’s instructions.
This is critical and typically involves the following steps:
1. All personnel handling contaminated scopes should wear the appropriate personal protective equipment (PPE), which consists of a fluid-resistant gown with full sleeves, gloves, and face and eye protection. The scope should not be pre-cleaned next to the patient because of the potential exposure to aerosolized detergents and bioburden.
2. To remove all gross soil, wipe the scope’s insertion tube with a clean, lint-free, soft cloth and water containing an approved pre-cleaning agent. Be sure to follow the manufacturer’s dilution concentration and usage recommendations. Note: Specialty cleaning cloths and foam devices designed for this purpose are available from third party manufacturers.
3. Suction clear water through the scope.
4. The scope should then be coiled into a large circle configuration without kinks and carefully placed into a sealed container with no other instrumentation placed on it for transport to the reprocessing area. Valves should be placed into a small container and moistened to prevent drying of residual soil during transport. All reusable accessories, such as biopsy forceps, snare wires or water bottles, should be gathered and placed into a third container.
5. The scope should be transported to the reprocessing area within 15 minutes of use and be placed into the reprocessing cycle for continued processing no later than 60 minutes after pre-cleaning. Failure to do so will allow the residual soil to dry and prevent adequate cleaning and disinfection of the scope. Note: Pre-cleaning in the processing area is appropriate, especially if there is a rapid turnover of scopes, and in instances where there will be a waiting time before the scope is placed into an automated washer or fully manually processed.
Ideally, the scope will be decontaminated in a dedicated location within a CSSD area that has side-by-side sinks for
(a) leak testing, (b) cleaning and (c) rinsing. The use of PPE is mandatory, and failure to provide and/or use this protection may lead to staff exposure and/or injury, and Occupational Safety Health Administration (OSHA) citations/fines. CSSD personnel must receive training for PPE selection and use, and must also be well-versed on all potential hazards related to scope reprocessing.
To pre-clean a scope, manipulate its valves and use the suction valve to draw clean water containing the approved concentration of pre-cleaning detergent water through the channels. This also helps to pre-clean the valves and demonstrates that the device remains functional. The scope should then be detached from the processor, and the
water-resistant cap should be placed and locked on the electrical connection port. Next, remove the suction and control valves, insert the cleaning channel valve device, and attach the cleaning adaptors and tubing provided by the manufacturer to flush out gross soil.
The first step in a scope’s cleaning cycle involves leak-testing to ensure the channels are intact and able to be cleaned.
A test failure indicates that a channel is perforated, torn or twisted. If this occurs, the scope must be tagged for repair,
and the OEM’s guidelines must be followed while it is cleaned, decontaminated and returned to the repair facility.
A leak test is performed under clean water (without detergent) using the leak tester (venting) connection that is typically on the water-resistant cap.
Note: Always ensure that the water-resistant cap is fully “on” and “locked.” The presence of air bubbles or the failure to maintain pressure during a manual or automated leak test is a positive indicator of an air leak.
The second step in a scope’s cleaning cycle involves flushing, wiping and brushing out each channel with appropriately-sized brushes designed for these purposes. This procedure should be repeated for each channel until no visible soil appears when the brush tip exits each channel’s distal end. Do not force the brush if resistance is encountered because either the brush is not the correct size, or there is a mechanical obstruction such as a “twist” in the channel/tube. In both instances, examination and repair will be needed.
The third step in the cleaning cycle involves detailed cleaning of scope accessories, including air and water control buttons and the biopsy port seals, and cleaning and hand-detailing any reusable instrumentation included with the scope.
Special soft brushes recommended by the manufacturer should be used to ensure the continued function of the parts and to prevent tears to the “O-rings.”
The scope should be thoroughly inspected for damage and repair requirements before placing the device into a high-level disinfection cycle that kills all organisms except spores.
Note: If spores must be eliminated, the scope must be sterilized with an ethylene oxide (EtO) or gas plasma process validated by the scope’s manufacturer. Using an incorrect process could damage the device and inadequately disinfect it. Many scopes use an “EtO-Plasma Only” cap that is placed on the venting connection to prevent damage to internal chambers and bending rubber while the scope is being EtO or gas-plasma sterilized.
All scopes should be inspected before and after patient use to identify those that may be damaged and pose a patient safety risk. Scopes that fail leak tests and visual inspections and/or have non-working controls should be tagged for repair and removed from scope storage. Strategies to reduce damage and loss of service availability include:
The safe and adequate handling, cleaning and disinfection of flexible scopes poses a significant and ongoing challenge to CSSD technicians. A trained and dedicated workforce should be tasked with handling these complex devices because patient safety depends upon skilled service and a fully functional and safe medical device.
Scott Davis, CMRP, CRCST, CHMMC
Susan Klacik, ACE, CHL, CRCST, FCS
Patti Koncur, CRCST, CHMMC, ACE
Natalie Lind, CRCST, CHL
David Narance, RN, CRCST
Carol Petro, CRCST, RN, BSN
Patti Koncur, CRCST, CHMMC, ACE
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