ENDOSCOPY
The delivery of safe endoscopic services is governed by overlapping standards including those for the design and staffing of the facilities, automatic endoscope reprocessors, chemicals, water quality and drying cabinets. (WGO, April 2019) The success of reprocessing depends on the healthcare provider’s facilities and quality of staff. During pre-cleaning, it is important to remove organic matter – this will help to reduce the possibility of drying and channel blockages (especially if there is a delay) before further manual cleaning takes place. It also helps to prevent the formation and build- up of biofilms and the drying of body fluids. The leak test is also important to ensure the integrity of the endoscope, Caesar pointed out. Any damage to the outer surface/channels could allow body fluids or chemicals into the internal workings of the endoscope.
Appropriate manual cleaning – brushing and flushing – of endoscopes also reduces the number of microorganisms and organic load by 4-6 logs or 99.99% biofilm removal. After manual cleaning, it is necessary to secure a controlled, validated, reproducible high level disinfection process. Additionally, drying is essential to prevent growth of possible remaining bacteria and proliferation of biofilm. This should be followed by storage in a safe, clean and dry environment. Endoscopes also need to be transported in a safe, clean and dry way. He pointed out that there can be many gaps in endoscope reprocessing – for example, damage of the endoscopes can lead to negative results in cleaning. Time delays (greater than 60 minutes) can also be very important as these can have implications for manual cleaning. In addition, inadequate or no leak tests can lead to damage of the endoscope, which leads to increased repair costs. Issues may include contaminated
washer-disinfectors; contaminated water; inadequate or no drying of the wet endoscope; or inadequate storage. Therefore, it is important to close these gaps and improve the reprocessing outcomes, Caesar continued.
Good instructions for use are crucial for damage control, while endoscope design is another important factor. Studies show that the elevator section of an endoscope is a particularly risky area, so the design of the elevator mechanism is extremely important. This prompted Pentax Medical to develop the ED34-i10T2 DEC Duodenoscope, which allows good access for cleaning. The company has also developed disposable suction valves, for its bronchoscopes, while its PROfILE single-use cleaning brushes also minimise reprocessing risks – effectively reducing soil and biofilm. By ensuring effective drying and storage,
JUNE 2022
the PlasmaTYPHOON+ and PlasmaBAG system can further help to reduce infection and patient risk. Ultimately, success factors include:
l A continuous and concerted focus on proper training of personnel.
l Closing the gap between all endoscopy facilities stakeholders – i.e. ensuring collaboration between the endoscopist, reprocessing professionals, nursing, infection control, biomedical engineering, patient safety professionals and management.
l Minimising human factors, by ensuring standardised and validated reprocessing efforts, as well as appropriate resources and training.
l Continuous and innovative engineering of endoscopes and other related products.
Endoscopy and sustainability Professor Shaji Sebastian, a consultant gastroenterologist at Hull University Teaching Hospitals, went on to issue ‘a call for sustainable practice in endoscopy’, highlighting the need to ‘care for people and the planet’. Global temperatures have risen 1.1 degrees C above pre-industrial levels and parts of the UK have experienced a four-fold increase in average rainfall, compared to 1981-2010. The UN has also described ocean plastic as a “planetary crisis”. Prof. Sebastian suggested that attention has been focused on tackling the crisis of COVID-19 and the following recession. However, the climate crisis has not gone away. So, why should we care as healthcare professionals? “Climate change is the number one public health issue of the 21st Century…Ironically, modern healthcare is a major emitter of environmental pollutants that adversely affect human health,” he explained. Prof. Sebastian went on to point out that GI and endoscopy is the third most hazardous healthcare waste generating department. This is due to:
l The high throughput of case load. l Multiple non-renewable waste streams. l Resource-heavy decontamination processes.
l Numerous hospital visits for patients and relatives.
“At every step, we have a high carbon footprint,” he continued. “To put this into perspective, the waste volume associated with endoscopic procedures undertaken annually, in the US alone, would cover the equivalent of 117 soccer fields (with waste at 1 metre in depth), and would weigh the equivalent of 24,900 passenger cars,” he commented. “This is why we formed the Green Endoscopy Group, with colleagues from the UK and the US.”5
The group has focused on
the principle of ‘reduce, reuse and recycle’ (the ‘3Rs’). First and foremost, reducing the volume of unnecessary procedures could have a significant impact on reducing environmental harm, as well as reducing the risk of harm to the patient.
The group has also mapped the patient journey using the ‘3Rs’ and outlined potential improvements. This includes rigorously checking the appropriateness of referrals, using low-waste alternatives (eg, faecal immunochemical tests, faecal calprotectin, video capsules, or CT where appropriate), or home testing to reduce travel (where technology allows and after effectiveness and safety have been established). Other improvements in the pathway may focus on reducing Do Not Attend (DNA) rates, use of virtual/tele-clinics, implementation of home/local testing, a move to paper-light/digital admin, rational use of PPE, use of low-carbon alternatives, a move to on-demand lighting, reduction of water wastage, digital image capture and use of electronic records – to name just a few. The Green Endoscopy Group is also targeting plastic waste.
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