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cleaned and rinsed endoscope undergoes improper or inadequate high-level dis- infection or liquid chemical sterilization processes, microorganisms can survive and transfer to the next patient, creating an opportunity for infection.
Properly processed endoscopes may
be exposed to contaminated surfaces or fluids before they are used. During leak testing and cleaning, sink fluids become contaminated by the endoscope. Brush- ing and flushing during cleaning create opportunities for splashes, spills and aerosolization of the contaminated fluids, which can reach as far as six feet from the sink. Moving or storing endoscopes within this space exposes them to con- taminated fluids, creating an opportunity for cross contamination. Another commonly forgotten source of contamination is personnel protective equipment (PPE). While PPE protects staff from splashes, spills, and aerosol- ized contaminants, the PPE materials and surfaces become contaminated. Gloves are the most likely equipment to create cross contamination opportunities. When PPE is not changed between highly contami- nated tasks, like cleaning, and tasks with less contamination, such as removing endoscopes from automated reprocessors, cross contamination can occur. It is com- monly believed that changing gloves (and not the fluid-resistant gown) prevents contamination. However, one touch of a cleaned endoscope to a contaminated gown can recontaminate the endoscope. Another source of cross contamination is the air. Room air can become contami- nated from aerosolized cleaning fluids, external contaminants coming in with the heating and cooling system air, and lint or dust carried by lint-generating activities, such as unpacking items from corrugated shipping boxes. Airborne contaminants can settle on drying or stored endoscopes. Pseudomonas aeruginosa and Klebsiella legionella are two microorganisms often found in small numbers within facil- ity water. When these microorganisms colonize a water system, large colonies can form, creating biofilms. Biofilms can release microorganisms into the water that could contaminate endoscopes dur- ing rinsing. Normally, this would not be a concern. However, when the conditions are right, these microorganisms can cre- ate a mature biofilm within endoscopes, which is extremely difficult to remove and kill.
Biofilms can form anywhere moisture pools or items remain damp for long
periods of time. Residual soils, holes in endoscope coverings, and damaged seals are perfect locations for biofilm forma- tion. Endoscopes stored wet can give rise to biofilms in the residual moisture. Sink drains, wet floors, and absorbent towels retain moisture for long periods of time and contributes to biofilm formation and the opportunity of cross contamination.
Simple ways to prevent cross contamination Preventing cross contamination requires a multi-pronged approach involving edu- cation, physical barriers, and mechanical controls to stop the spread of micro- organisms. The process begins with best practice. Several agencies provide guidance for processing flexible endo- scopes. The Society of Gastroenterology Nurses and Associates (SGNA), the Association of Professionals in Infection Control and Epidemiology (APIC), the Association for the Advancement of Medical Instrumentation (AAMI), and the Association of peri-Operative Registered Nurses (AORN) publish guidelines and standards for processing flexible endo- scopes. Of these organizations, AAMI and AORN have issued the most recent guidelines, both released in 2022.
Follow all equipment instructions Policies, procedures, and work instruc- tions should strictly follow the endo- scope’s instructions for use and the instructions of all items used to process the endoscope. Additionally, depart- ments should implement a documented and rigorous training program that tests the competency of staff members processing endoscopes, and this com- petence should be regularly reviewed. Some organizations recommend certify- ing staff members who process flexible endoscopes. Several trade organizations, colleges and universities offer programs specific to the processing and manage- ment of endoscopes. Facilities should consider implementing programs that encourage certification in flexible endo- scope processing.
Separate dirty and clean
Most organizations agree that process- ing should be divided into two rooms. The first room, decontamination, receives soiled endoscopes, leak tests, cleans, rinses, and inspects. In the second room, or clean room, technicians high level disinfect or liquid chemically sterilize the endoscopes and dry them. Endoscopes should always
SELF-STUDY SERIES travel unidirectionally from areas of high
to low contamination. The decontamination room should be at a negative pressure as compared to the adjacent hallways and rooms. This ensures that air flows into the room from the adjacent areas, keeping micro- organisms that may be in the air, from escaping to adjacent areas causing cross contamination. The heating and cooling system should exchange the room air with fresh air to reduce the total airborne contamination within the room. ANSI/ ASHRAE/ASHE Standard 170 Ventilation of Health Care Facilities specifies the rela- tive negative pressure, room air exchange rate, and air management for potentially contaminated air. Endoscopy processing supervisors should work with facilities to ensure compliance to the standard’s revi- sion that applies to the specific model of ventilation system in their facility.
Keep sinks away from inspections Within the decontamination space, splashes, spills, drips and aerosolization of contaminated cleaning solution and rinse water carry microorganisms to sur- faces, counters, walls, floors, and equip- ment around them. One study showed that splashes could reach as far as six feet from the sink. For this reason, it is nec- essary to physically separate sinks from endoscopes undergoing inspection. AAMI recommends a minimal distance of four feet. If this is not possible, a physical bar- rier extending four feet from the sink’s rim towards the ceiling should separate the sink from inspection space.
Clean sinks and surfaces
To prevent potential cross contamina- tion between endoscopes, sinks should be drained, cleaned, and disinfected after each endoscope. Clean spills, sprays, and drips immediately. Regularly clean and disinfectant surfaces that may become contaminated during decontamination of endoscopes. Faucet handles, cleaning solution dispensers, leak testing equip- ment, flushing tubing and connectors, counters, and floors are a few items to consider. Ensure regular cleaning and dis- infection of high contact points like door handles, cabinet pulls, and equipment contact points within the room. Always follow manufacturer instruction for use to ensure proper use of cleaning solutions, disinfectants, and disinfection methods for equipment.
Clean inspection equipment During inspection, drips, aerosolization from blowing channels clear of fluid, and
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Self-Study Test Answers: 1. A, 2. B, 3. D, 4. B, 5. A, 6. D, 7. C, 8. D, 9. C, 10. C
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