An eye toward repair reduction:
Tips on organizing your GI lab

Maintaining an optimal scope inventory is fundamental to keeping repair expenditures at a minimum. Monitor the size and age of your resource pool and appropriately balance your scope inventory against your current and forecasted procedural requirements. Do you have the right scopes to meet current and predicted case-mix demand? Too many of the wrong scopes can unnecessarily lock up excessive capital; too few of even the right scopes may delay procedures. This can lead to patient and physician dissatisfaction, unplanned staff overtime and increased scope handling-related repairs. Benchmark data for 2008 showed that endoscopes per procedure room averaged: 2.0 workhorse (those used most often) upper scopes; 3.1 workhorse lower scopes; and 0.2 and 0.3 specialty scopes for upper and lower procedures, respectively.1 The following chart further breaks down scope inventory per facility type.

Benchmarking data from similar facilities can help you evaluate your own scope mix, ensuring you get the most mileage out of your capital equipment budget. You can also look at the number and frequency of procedure start delays and cancellations resulting from unavailable equipment. This will provide a good indicator of whether your inventory sufficiently meets your typical procedural load.

Additionally, it is important to evaluate your inventory relative to its age. If you hang onto a workhorse scope for too long, repair expenditures may start to climb while your technology edge plummets. Benchmark data for 2008 shows
the median age of all endoscopes as 2.6 years, with the overall average ages of workhorse endoscopes reported as: colonoscopes (3.0 years), EGD scopes (3.1), ERCP scopes (3.0) and EUS scopes (2.4).1

There is much to be said for a well organized and effectively designed facility. The most efficient and cost-effective labs have taken into consideration the dynamics of staff, equipment and workspace. Below are a few questions to think about with respect to your own facility.

• Do you have an appropriate number of prep and recovery bays to meet the needs of your case mix and volume? For example, are cases delayed because patients cannot be moved efficiently out of the procedure room into the recovery room? Benchmark data in 2008 reveals the ratio of prep and recovery bays to procedure rooms as 4:1 in both single specialty ASCs and non-teaching hospitals and 3:1 in teaching hospitals.1

• Do your workspaces follow a dirty-to-clean flow? Is the reprocessing room close to the procedure room for convenient transport of the dirty scopes and accessories in a dirty-to-clean path? This is important not only for infection control purposes, but also to ensure scopes and staff move through the space in an efficient way, allowing sufficient time for safe and proper handling and scope reprocessing.

• Does the procedure room have adequate space to safely protect endoscopes before, during and after procedures?

• Does your facility have dedicated clean scope storage, separate from accessories?

In short, a workspace that enhances effective operational throughput may mean less rushing and fewer incidents of damage. Most importantly, achieving optimal efficiency allows more time to ensure that proper protocols for transport, handling, set up, reprocessing and storage are followed.

Equally as important as a well-designed facility; GI labs must structure reprocessing protocols and processes as well as the workspace to maximize the throughput of scopes while minimizing the risk of scope damage.

Location: As stated in the Society of
Gastroenterology Nurses and Associates, 2008 Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes, "Reprocessing of contaminated patient equipment should be done in an area designated and dedicated for this function. This should be a room separate from where endoscopic procedures are performed."

Failure to properly clean endoscopes produces a host of avoidable consequences that drain resources from safe, effective delivery of GI endoscopy services. As previously mentioned, this dedicated area ideally should be located close to the procedure rooms. Additional time spent moving scopes to remote sites may inadvertently encourage infection control risks associated with delayed reprocessing. Always check with your original
endoscope manufacturer (OEM) for instructions on delayed reprocessing.

In addition, to expedite transport to remote reprocessing areas, staff may be more tempted to tightly coil and stack scopes together or scopes and accessories together in the same transportation bins. Such shortcuts make scopes more vulnerable to kinks, cuts, punctures and other damage.

Time: In the reprocessing area, allow staff adequate time to complete all cleaning, disinfection and sterilization (CDS) steps in accordance with original equipment manufacturer’s (OEM) guidelines. The procedural schedule can often get hectic. Unfortunately, the more rushed the reprocessing technician gets, the more opportunity there is to omit steps, causing endoscope damage and downtime. Insufficient or improper leak testing can result in accidentally missing a small leak, which left unchecked can escalate into a major repair. Failure to inspect water-resistant caps before attaching them to the scope or forgetting to attach the water-resistant cap before immersing the scope into the basin of water can also cause damage and additional repair work that could have largely been avoided.

On average, 2008 benchmark reprocessing time data showed that 8.2 minutes were required for leak testing and mechanical cleaning, 32.5 minutes for AER cycle time and 6.4 minutes for post-automated time, for a total of 47 minutes from start to finish.1 Compare your average scope turnaround time from patient scope extraction until the scope is once again patient ready. This is one benchmark whereby faster is not necessarily better. Factor in sufficient time to cover all of the necessary reprocessing steps based on your staff and equipment requirements.

Protocols and processes: Make sure to complete pre-cleaning in the procedure room. Pre-cleaning removes bioburden before it has a chance to harden, avoiding the need for more aggressive cleaning and potential damage to the scope. Check the integrity of the water-resistant cap, making sure it is dry and attach it to the scope at bedside. Transport scopes to the reprocessing area in covered containers. Then in the reprocessing room, always perform leak testing prior to moving on to manual cleaning and high-level disinfection. Consistent leak-testing practices can help you largely avoid fluid invasion damage to the scope, which is the number one cause of expensive, refurbishment-level repairs. (More information about avoiding fluid invasion is available at olympusamerica.com/msg_section/files/handleendoscopes withcare.pdf.)

Space: The reprocessing room should be of adequate size with proper ventilation. Check the sink and drain and work areas to ensure they are free of sharp edges. Remove all unnecessary objects that might inadvertently damage the endoscope. The reprocessing room should leave ample counter space for leak testers, basins, flushing pumps and so forth so that there is adequate room to maneuver the scopes without stacking or bumping them into other equipment.

Benchmark data indicates that appropriately sized reprocessing space is a recognized and ongoing issue. Just over 10 percent of survey participants in 2008 agreed that their workspace was too small.1

Sinks: Use a sink large enough to avoid crimping the instrument during leak testing and manual cleaning. The sink should be deep enough to allow full immersion of the endoscope to effectively accomplish leak testing and manual cleaning. Never use sinks to stack scopes waiting for leak testing and manual cleaning.

AERs: If your facility uses automated endoscope reprocessors (AER), make sure you have the appropriate number and types of machines to adequately process your volume of scopes. Benchmark data for 2008 shows that the average number of scopes which can be reprocessed at once per endoscope procedure room is 1.3.1

It is also a good idea to design enough space to allow access for planned and unplanned maintenance and repairs. Make sure you are using an AER that is appropriate for the types of scopes at your facility. Use caution and care when placing and removing scopes from AERs. Follow the scope manufacturer’s instructions for use of the AER and for approved protocols for high-level disinfection or sterilization. Also, use only FDA-approved liquid chemical germicides (LCG) recommended by the endoscope manufacturer to protect your equipment from chemical damage. LCG potencies should be tested and recorded prior to every cycle. Staff can avoid undue chemical damage to the scope as well as cross-contamination risks by adhering to the detergent and/or disinfectant/sterilant OEM’s instructions for reprocessing times, temperatures, dilution, shelf life and expiration.

To safeguard endoscopes when they are not in use, store them in clean, dry, well-ventilated, protective cabinets maintained at an ambient temperature. Store endoscopes without valves and caps; they can trap moisture in the channels and promote unwanted microbial growth. A well-ventilated storage cabinet reduces the chance of microbial contamination by encouraging continued air-drying of the endoscope’s surfaces and channels.

Proper storage of the endoscope should support the control body. The insertion tube and universal cord should hang in a vertical position with the distal tip hanging freely. Finally, to prevent stretched or broken angulation wires, place the angulation locks in the unlocked position.

Never store endoscopes in their carrying cases. Use appropriate carrying cases or shipping containers for transporting endoscopes to and from repair facilities. Do not pack the scopes with accessories to prevent further damage during transport.

An ounce of prevention can heavily influence your repair expenditures. Fix minor damage quickly before it escalates. This includes ensuring regularly scheduled preventive maintenance checks,
habitually checking instruments and equipment for wear, and documenting post-repair inspections of all returned endoscopes. Systematically track and trend scope repairs by individual scope serial number. This type of data will help point to areas of reprocessing that need improvement. Finally, keep appropriate staff trained on handling, operating and reprocessing practices and protocols.

Every member of your staff, from physician to technician, needs to understand the direct correlation between proper endoscope care and handling and repair expenditures. This is particularly true of reprocessing staff. Facilities that have the lowest rate of repairs tend to have highly trained, dedicated reprocessing staff members that have been given ownership of the reprocessing responsibilities. These staff members comprehend that skipping and/or ineffectively performing reprocessing steps, or failing to follow OEM instructions, can adversely affect patient safety and directly increase the incidence and cost of repair.

As already noted, it is important for all staff working with endoscopes to receive proper training and to keep current on handling, operating and reprocessing protocols. Proper handling and CDS protocols go a long way toward maintaining properly operating equipment, reducing repair expenditures and supporting positive infection control outcomes. Seek the support and resources of your scope manufacturer to help you train your staff on this important topic. (More information is available at www.olympusamerica.com/cds, www.olympusamerica.com/endoscopecare, www.olympusamerica.com/reprocessing and www.olympusuniversity.com.)

One very positive note for the GI and bronchoscopy industry is that a new Certified Flexible Endoscope Reprocessor exam was introduced in the United States in February 2008. All reprocessing staff should be encouraged to take this important test. The exam provides the industry with a set of uniform guidelines and standards for evaluating the knowledge and skill set necessary to competently fill this critical reprocessor position. (More information is available at sterileprocessing.org.)

6 tips for proper, patient-safe scope repair inspections