Decontamination
Risk and revolution in endoscope cleaning
The Central Sterilising Club’s Annual Scientific Meeting explored “risk and revolution” in endoscope reprocessing and highlighted some of the innovation taking place in the sector. Louise Frampton provides an insight into some of the key discussion points.
Jim Tinsdeall, an AE(D) with over 30 years’ experience in the NHS, including health estates, gave a thought-provoking discussion on the key considerations around recent innovations in endoscope cleaning. He opened with a key message with relevance for sterile services today – both in terms of the human tendency for blame culture and the importance of retaining the original safety lessons from historical safety incidents. He illustrated the point with the example of
the great fire of London, which was originally blamed on an innocent party – a Frenchman, Robert Hubert, who was wrongly executed, despite being out of the country at the time of the fire. A rebuilding act for London, in 1666, stopped the practice of cladding buildings in timber. But during the 2000s, there was a change in building practices, driven by a ‘green revolution’.
He explained that, in a bid to reduce the consumption of energy, there was a “quiet revolution that allowed us to clad a building which burned in 2017 [Grenfell Tower].” He added that this demonstrates that “we must keep the original learning that we had from an incident and not let that go to waste.” For sterile services, a major reference event is the ‘Devonport incident’. This occurred in 1972, in the UK, when a batch of intravenous fluid was not properly sterilised. This led to a public health emergency, fatalities, and a search for unused product in the distribution network. There followed a government enquiry, which is summarised in the Clothier Report (July 1972). In this report, poor operational practices surrounding the final sterilisation autoclave were blamed for the problem. A contributing factor was the fact that, although there were quality control checks, the assessed bottles were only taken from the top shelf. Therefore, the failure wasn’t detected and contaminated product was issued for use. For context, the final conclusions of the
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report stated: “The committee considers that too many people believe that sterilisation of fluids is easily achieved with simple plant, operated by men of little skill, under minimum supervision – a view of the task which is wrong in every respect.” Jim Tinsdeall explained that patients affected
by this incident died of exposure to endotoxins derived from dead bacteria in the fluid. He pointed out that one of the key lessons learnt from this incident included the need for track and trace – tracking 500 bottles of fluid proved to be extremely problematic. “Was it a defect of the steriliser in terms of design? Probably not. In terms of maintenance and validation, and improving the thing it was supposed to do, then most definitely,” he commented. Jim Tinsdeall went on to consider the decontamination of endoscopes. There are multiple channels that need to be cleaned – including the biopsy channel, air and water channel, and the auxiliary channel. He pointed
out that it can be very challenging to clean these channels manually and biofilms can present significant issues. “There’s very little agitation in the smaller lumens. Air and water channels may not be cleaned; they might have a little bit of irrigation. We could be doing that irrigation with just a syringe,” he commented. “We’ve got the bedside clean immediately after use; we then have the manual clean, and then the endoscope washer disinfector…I’ve had some people say some of the lumens are quite scratched and we don’t know whether that’s the brushing, or the devices they’re dragging through them when performing a biopsy.”
He went on to discuss the human factors in manual processes that can create risk – staff do not always work consistently and can be affected by fatigue or other issues. “Looking at your staff, how many days do they give one hundred percent? Would it be 80% of the time? 90% of the time, 50% of the time?” he commented. “Fifteen to 20 minutes is needed
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