Don’t let hang-time become a hang-up

Oct. 25, 2021
Aeration, drying and storage represent integral finishing steps for patient safety

From pre-treatment at the point of use to visual inspections and leak testing to cleaning to high-level disinfection and rinsing to sterilization, the process to reprocess endoscope devices and instruments can be as complex as the products themselves.

But the final step in the reprocessing process – aeration, drying and storage – before handling/transportation to the point of use and ongoing maintenance and repair – represents the last and perhaps most important quality checkpoint before those endoscopic devices and instruments exit Sterile Processing & Distribution (SPD) on the route back to Surgical Services.

Because that closing step remains so essential for patient safety, Healthcare Purchasing News recruited a small group of SPD experts to share useful tips and tricks to ensure ready-to-use endoscopic devices and instruments. Here’s what they recommend.

Melinda “Mindy” Benedict, MS, CIC, CFER, Global Senior Manager, Infection Prevention, Olympus Corporation of the Americas, emphasizes that endoscope drying and storage play a key role in endoscope reprocessing as it is important to stress that preventing the introduction of contaminants after disinfection is pivotal to patient safety. Benedict’s tips on drying and storing reprocessed endoscopic devices:

  1. “The quality of compressed air used to dry endoscopes is important.  Inadequately filtered air could introduce contaminants to a clean endoscope. Societies are moving toward the use of instrument-quality air. The AORN guidelines state, “The exterior surfaces of the endoscope should be dried with a soft, lint-free cloth or sponge and all channels purged with instrument air.”1 GNA indicates that step No. 8 in endoscope reprocessing is drying, “which requires an alcohol flush, followed by forced-air drying with instrument-quality compressed air.”2
  2. “Heathcare facilities may want to consider avoiding the use of oil-based compressors for drying endoscopes.
  3. “When drying endoscope channels, be sure the maximum air pressure introduced does not exceed manufacturer IFU requirements. The latest Multisociety Guidelines recommend, “Endoscopes should be completely dried after reprocessing and before use.”3
  4. “Whenever possible, store the endoscope in a drying cabinet. If a drying cabinet is not available, dry the endoscope (exterior and lumens) and hang it in a well-ventilated HEPA cabinet that provides positive pressure.
  5. “Once disinfected, endoscopes should be dried and stored in a way that will protect them from external contaminants. Hang the endoscope in a vertical position to enable drying and maintain scope integrity. Remove caps, valves, and other detachable parts per IFU instructions.”

Ron Banach, Director of Clinical Education, Ruhof Inc., urges SPD pros to look intricately for moist and dark lumens.

“Once the endoscope [high-level disinfection] process has been completed, studies have reported that bacteria growth can occur in a moist and dark lumen. There are scope drying devices or endoscope storage cabinets with a HEPA-filtered air flow pump that use connector tubing attached to the endoscopes lumens/channels while it hangs in the storage cabinet.”

Melissa Kubach, Clinical Education and Training Manager, National Solutions Team, Agiliti recommends following the proper order of things.

“Proper drying of flexible endoscopes has taken priority over hangtime. Fully dried endoscopes are essential for discouraging conditions that facilitate bacterial growth. There are many methods and products currently available for completing effective drying.

“Drying principals are simple, but often misunderstood. The air must be HEPA-filtered at minimum to avoid blowing contaminants and particulates into the channels. It is necessary to control temperature and humidity conditions, as well as utilize multiple filters, including ULPA and oil filtration, when employing traditional mechanical air compressors. Storage areas and cabinet conditions should be monitored for humidity and temperature as well.

“Many users associate drying with air pressure (PSI), which is not the correct correlation for highly effective drying. Instead, the emphasis should be on airflow, which facilitates thorough and timely drying through air circulating over the drying surface, which is measured in cubic feet per minute (CFM).

“Drying time should be ample to address the hard-to-dry internal channels. Keep in mind, lengthy small diameter channels are the most difficult to dry, especially without automated drying. If drying takes place prior to storage, then cabinet conditions should encourage maintaining the ‘dry’ status. This may include circulated or positive air pressure and/or continuous air feed within the channels.”

Shaun Sweeney, Vice President, Cygnus Medical, cautions that gravity doesn’t solve everything.

“The past five years have introduced several eye-opening studies that have shown the amount of water remaining in the channels after [high-level disinfection] reprocessing. For years the common practice and assumptions, were that by hanging a scope long enough gravity would remove any droplets from the channel. A good portion of the water is removed this way.  However, trails of tiny micro droplets are left behind in the process, and sometimes large droplets. At their level of atomic mass, the surface tension of water is stronger than the forces of gravity leaving the droplets there indefinitely. With no natural air exchange there is no mechanism for evaporation, so the droplets remain.

“Also in question is the role of an IPA alcohol purge. We have found in our studies that although there is a benefit the effect and results have been grossly overstated. The most effective process is evaporation through a continuous air flow. We have found the same results whether scopes are dried vertically or horizontally and with or without an alcohol purge.”

John Whelan, RN, Clinical Education Specialist, Healthmark Industries, suggests surpassing well beyond the urge to purge.

“The drying that occurs in an automated endoscope reprocessor (AER) is a purge, not an intentional drying cycle. Anyone who has removed an endoscope from an AER knows it is still wet on the outside, and water drips from the channels. Scopes need to be purposely dried at the end of processing, even when an AER is used. Clinical investigations and research have shown that fluid remains in endoscope channels for days after placed in storage. This provides an ideal environment for microbial contamination and biofilm growth.

“Current expectations from standards and guidelines call for:

  • Active HEPA-filtered forced air drying prior to storage, or the use of HEPA-filtered forced air-drying cabinets (where endoscope channels are connected to continuous airflow); and
  • Active drying post-processing – regardless of whether the scope is headed to another procedure or into storage.

“The good news is that multiple options for drying are already on the market, and more are coming. These include drying cabinets as well as table-top dryers. As with any automated process though, it will be important to periodically perform quality control testing. This is where drying verification tests come in. These are very easy and quick ways to corroborate channel drying adequacy.

“Reprocessed items post high-level disinfection are not packaged like sterilized items that are in peel pouches or trays, so you can’t tell just by looking at the device that it’s been through processing. A scope after processing can look the same as a scope pre-AER. This calls for visual cues on the individual endoscope – before leaving the processing area. This means a label or tag attached to the scope that includes:

  • the processing date
  • the name(s) of the person(s) who performed the processing
  • expiration (‘hang time’) date, based on the facility’s established risk assessment.

“Multiple options exist for endoscope tags and labels, including various colors, blank or pre-printed, hang tag and zip tie options.”

David Willoughby, Vice President, Marketing & Business Development, Medtrica, stresses keeping each device separated and secure.

  • “Hang in containers or cabinets with unrestricted clean airflow so that gravity and clean air movement can effectively help with aeration and drying.
  • “Do not allow instruments to make contact with another instrument or itself during storage.
  • “Use a disposable and breathable cover to act as a physical barrier between the instrument itself, other instruments and the environment during both storage and pre-procedural transport
  • “Use a disposable and breathable paper-based cover on the insertion tube during storage to wick away any remaining moisture after reprocessing.
  • “Use a sterile cover to protect the distal end of an instrument during storage and transport, one that is not only disposable and breathable, but also one that is constructed with non-porous/non-absorbent materials.”

Gregg Agoston, M.B.A., Vice President, Business Development, SPD Transformation Services, SpecialtyCare, reminds SPD pros not to proceed to the aeration/drying/storage step if prior steps have not been satisfied.

“If a flexible scope fails leak testing upon the return of the instrument to the processing area, this failure means that the instrument technically was not sterile or high-level disinfected during the procedure unless it can be documented that the cause of the leak test failure happened post-case. No one would ever allow a flexible endoscope to be used in a procedure if it was known to have a leak.” 

References
1   Association of periOperative Registered Nurses. Guideline for Processing Flexible Endoscopes. Revised February 2016 for publication in Guidelines for Perioperative Practice, 2016 edition
2   Society of Gastroenterology Nurses and Associates. Standard of Infection Prevention in the Gastroenterology Setting. 2016.
3   Multisociety Task Force Article. Guideline on reprocessing flexible GI endoscopes and accessories. 2021.

Continue reading …

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Don’t let hang-time become a hang-up
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Original photo courtesy Bayhealth SPD, HPN's 2021 SPD of the Year, with affects added by generative AI.
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