Multisociety guideline on reprocessing flexible GI endoscopes and accessories

A New Drying Method of Thermolabile Flexible Endoscope Channels by Laminar and Turbulent Airflow: A Prospective, Randomized-Controlled, Single-Center, Proof-of-Concept Trial

INTRODUCTION

International guidelines suggest different possibilities for drying of endoscopes during reprocessing. Clinical results of these available drying methods are not satisfactory. The aim of this study was to compare the drying cycle of a standard endoscope washer-disinfector (EWD) (standard drying method [SD]) with a shortened mandatory drying by the EWD followed by a special drying device using laminar and turbulent air flow (novel drying method [ND]).

METHODS

Sixty endoscopes (duodenoscopes, colonoscocopes, and gastroscopes) from 3 different manufacturers underwent high-level disinfection and drying depending on the randomization group. Operational time of drying was measured for both groups. Residual fluid in the channels was measured using a laboratory scale. After a 14-day storage period, a sample of the endoscope channels was obtained to determine bacterial contamination.

RESULTS

ND had significantly fewer residual water in endoscope channels (SD: 90% vs ND: 0%; P < 0.001) after high-level disinfection and drying and less bacterial contamination after storage for 14 days (SD: 47% vs ND: 20%; P = 0.028). Time consumed for drying in ND was also significantly shorter (SD: 16 minutes 4 seconds vs ND: 5 minutes 59 seconds; P < 0.001).

DISCUSSION

Drying with a special automatic drying device was superior compared with an EWD's drying program as evidenced by no measurable residual water, reduced microbiological contamination, and a more than 2-fold decrease in operational time. Thus, drying by laminar and turbulent airflow may represent an attractive alternative to the currently used standard approach in the reprocessing process of flexible endoscopes.

Impact of Different Pressures on the Drying Time of Flexible Endoscopes

BACKGROUND

The complex structure of endoscopes causes nonuniform drying conditions. However, current clinical drying practices lack precise guidance, leading to the insufficient drying of some endoscopes, which increases the risk of infection. The pressure of compressed air has been proven to affect the effectiveness of endoscope drying; however, specific requirements are absent. This study explored the time required for the sufficient drying of different endoscopes under various pressure conditions.

METHODS

Six different types of commonly used Olympus flexible endoscopes were selected, and for each type, multiple drying time groups were set under pressures of 0.102 and 0.204 MPa, with 10 endoscopes observed in each group.

RESULTS

Drying times varied according to the type and pressure. At 0.102 MPa, the instrument channel drying ranged from 80 s to 160 s (avg. 123 s), while suction channel ranged from 260 s to 540 s (avg. 428 s). At 0.204 MPa, the instrument channel dried in 50 s to 90 s (avg. 72 s), and suction channel in 130 s to 230 s (avg. 186 s).

CONCLUSIONS

Optimal drying times for endoscopes differ according to the type and pressure. A higher pressure (0.204 MPa) efficiently removes moisture and speeds up drying. Longer endoscopes with the same biopsy channel diameter require longer drying time. In addition, the instrument channel dries faster than the suction channel.

Sampling methods for flexible endoscopes without a working channel: a scoping review

BACKGROUND

A diagnostic flexible laryngoscopy using a flexible endoscope (FE) without a working channel can become contaminated when inserted through the nose to inspect the throat. Microbiological surveillance is necessary to ensure adequate reprocessing. A lack of knowledge exists about the most accurate way to assess microbiological contamination on the surface of FEs without a working channel. A scoping review of research on sampling techniques for FEs without a working channel was done to identify frequently used sampling techniques and to determine the best way to assess microbiological contamination.

METHODS

PubMed, Embase, Cochrane Library, and CINAHL databases were searched. Data related to the sampling technique and bacterial contamination were extracted.

RESULTS

Twelve of the 378 studies met the inclusion criteria. None compared sampling techniques, most studies investigated the efficacy of several disinfection methods. Retrieved sampling techniques were immersion, swabbing, and wiping. Immersion and wiping could detect bacterial contamination on contaminated FEs without a working channel. Two out of six studies using a swabbing method found bacterial contamination on contaminated FEs without a working channel. Three studies using the swabbing method detected bacterial contamination after disinfection. One study did not retrieve microorganisms after disinfection using the swabbing method.

CONCLUSIONS

Three different sampling techniques were extracted: immersion, wiping, and swabbing, which could all detect microbiological contamination on contaminated FEs without a working channel. However, this scoping review identified significant gaps in literature. Additional research is needed to determine the best sampling technique(s) for FEs without a working channel to detect microbiological contamination.

Using vaporized hydrogen peroxide for anhydrous disinfection of gastrointestinal endoscopes

BACKGROUND

Current disinfection methods for gastrointestinal endoscopes consume a significant amount of water resources and produce a large volume of waste.

AIM

To achieve the objectives of efficiency, speed, and cost-effectiveness, this study utilized vaporized hydrogen peroxide (VHP) generated from sodium percarbonate granules to conduct an anhydrous disinfection test on gastrointestinal endoscopes.

METHODS

The experimental device rapidly converts sodium percarbonate granules into VHP, and performs disinfection experiments on gastrointestinal endoscope models, disposable endoscopes, and various types of reusable gastrointestinal endoscopes. Variables such as the intraluminal flow rate (FR), relative humidity (RH), exposure dosage, and organic burden are used to explore the factors influencing the disinfection of long and narrow lumens with VHP.

RESULTS

The device generates a certain concentration of VHP that can achieve high-level disinfection of endoscope models within 30 minutes. RH, exposure dosage, and organic burden significantly affect the disinfection efficacy of VHP, whereas the intraluminal FR does not significantly impact disinfection efficacy. All ten artificially contaminated disposable endoscopes achieved satisfactory disinfection results. Furthermore, when this device was used to treat various types of reusable endoscopes, the disinfection and sterilization effects were not significantly different from those of automatic endoscope disinfection machines (using peracetic acid disinfectant solution) (P > 0.05), and the economic cost of disinfectant required per endoscope was lower (1.5 China Yuan), with a shorter disinfection time (30 minutes).

CONCLUSION

The methods and results of this study provide a basis for further research on the use of VHP for the disinfection of gastrointestinal endoscopes, as well as for the development of anhydrous disinfection technology for gastrointestinal endoscopes.

Endoscope processing effectiveness: A reality check and call to action for infection preventionists and clinicians

BACKGROUND

Flexible endoscopes are heavily exposed to blood, mucus, and other secretions during procedures and may harbor billions of microbes before processing. Guidelines recommend thorough cleaning and sterilization or high-level disinfection (HLD) after each use.

METHODS

This review describes evidence on the effectiveness of HLD from a robust review of peer-reviewed journals, adverse events reports posted by the Food and Drug Administration, and other government reports published during 2019-2024.

RESULTS

Although HLD theoretically eliminates viruses, fungi, and bacteria (except a few resilient spores), numerous studies found it did not reliably eliminate microbes in real-world settings, and a large proportion of endoscopes harbored substantial bioburden and potential pathogens. Dozens of endoscopy-associated outbreaks have been reported in the past 5years, including several involving multidrug-resistant organisms. When contaminated endoscopes or endoscopy-associated infections were discovered, investigators commonly found that personnel were skipping essential steps or doing them improperly.

DISCUSSION

To reduce infection risk and enhance patient safety, infection preventionists, clinicians, sterile processing and departmental managers, and other leaders should review the evidence, perform risk assessments, and implement proactive strategies for quality improvement in their facilities.

Optimizing bowel preparation quality for colonoscopy: consensus recommendations by the US Multi-Society Task Force on Colorectal Cancer

This document is an update to the 2014 recommendations for optimizing the adequacy of bowel cleansing for colonoscopy from the US Multi-Society Task Force on Colorectal Cancer, which represents the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy. The US Multi-Society Task Force developed consensus statements and key clinical concepts addressing important aspects of bowel preparation for colonoscopy. The majority of consensus statements focus on individuals at average risk for inadequate bowel preparation. However, statements addressing individuals at risk for inadequate bowel preparation quality are also provided. The quality of a bowel preparation is defined as adequate when standard screening or surveillance intervals can be assigned based on the findings of the colonoscopy. We recommend the use of a split-dose bowel preparation regimen and suggest that a 2 L regimen may be sufficient. A same-day regimen is recommended as an acceptable alternative for individuals undergoing afternoon colonoscopy, but we suggest that a same-day regimen is an inferior alternative for individuals undergoing morning colonoscopy. We recommend limiting dietary restrictions to the day before a colonoscopy, relying on either clear liquids or low-fiber/low-residue diets for the early and midday meals. We suggest the adjunctive use of oral simethicone for bowel preparation before colonoscopy. Routine tracking of the rate of adequate bowel preparations at the level of individual endoscopists and at the level of the endoscopy unit is also recommended, with a target of >90% for both rates.

Optimizing Bowel Preparation Quality for Colonoscopy: Consensus Recommendations by the US Multi-Society Task Force on Colorectal Cancer

This document is an update to the 2014 recommendations for optimizing the adequacy of bowel cleansing for colonoscopy from the US Multi-Society Task Force on Colorectal Cancer, which represents the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy. The US Multi-Society Task Force developed consensus statements and key clinical concepts addressing important aspects of bowel preparation for colonoscopy. The majority of consensus statements focus on individuals at average risk for inadequate bowel preparation. However, statements addressing individuals at risk for inadequate bowel preparation quality are also provided. The quality of a bowel preparation is defined as adequate when standard screening or surveillance intervals can be assigned based on the findings of the colonoscopy. We recommend the use of a split-dose bowel preparation regimen and suggest that a 2 L regimen may be sufficient. A same-day regimen is recommended as an acceptable alternative for individuals undergoing afternoon colonoscopy, but we suggest that a same-day regimen is an inferior alternative for individuals undergoing morning colonoscopy. We recommend limiting dietary restrictions to the day before a colonoscopy, relying on either clear liquids or low-fiber/low-residue diets for the early and midday meals. We suggest the adjunctive use of oral simethicone for bowel preparation before colonoscopy. Routine tracking of the rate of adequate bowel preparations at the level of individual endoscopists and at the level of the endoscopy unit is also recommended, with a target of >90% for both rates.

Optimizing Bowel Preparation Quality for Colonoscopy: Consensus Recommendations by the US Multi-Society Task Force on Colorectal Cancer

This document is an update to the 2014 recommendations for optimizing the adequacy of bowel cleansing for colonoscopy from the US Multi-Society Task Force on Colorectal Cancer, which represents the American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy. The US Multi-Society Task Force developed consensus statements and key clinical concepts addressing important aspects of bowel preparation for colonoscopy. The majority of consensus statements focus on individuals at average risk for inadequate bowel preparation. However, statements addressing individuals at risk for inadequate bowel preparation quality are also provided. The quality of a bowel preparation is defined as adequate when standard screening or surveillance intervals can be assigned based on the findings of the colonoscopy. We recommend the use of a split-dose bowel preparation regimen and suggest that a 2 L regimen may be sufficient. A same-day regimen is recommended as an acceptable alternative for individuals undergoing afternoon colonoscopy, but we suggest that a same-day regimen is an inferior alternative for individuals undergoing morning colonoscopy. We recommend limiting dietary restrictions to the day before a colonoscopy, relying on either clear liquids or low-fiber/low-residue diets for the early and midday meals. We suggest the adjunctive use of oral simethicone for bowel preparation before colonoscopy. Routine tracking of the rate of adequate bowel preparations at the level of individual endoscopists and at the level of the endoscopy unit is also recommended, with a target of >90% for both rates.

Novel water-based automated endoscope cleaning process vs conventional manual cleaning for reducing duodenoscope contamination

Background and study aims

Duodenoscope contamination remains a persistent problem, exposing patients to infection risks. Automation in reprocessing may limit human error, reduce workload, and increase uniformity and traceability. However, its effectiveness should be evaluated before implementation. This study assessed the impact of implementing a novel water-based automated endoscope cleaning process on duodenoscope contamination.

Methods

This before-and-after intervention study compared duodenoscope cleaning methods. From January 2022 to December 2023, conventional manual cleaning was used. From January 2024 to June 2024, the AquaTYPHOON system (AT) replaced manual cleaning. Cultures from Pentax ED34-i10T2 patient-ready duodenoscopes were collected. The main outcome was the contamination rate with microorganisms of gut or oral origin (MGO). Secondary outcomes included contamination with solely gut bacteria. Non-inferiority of the AT was tested using a generalized estimating equation with a non-inferiority margin of 5%.

Results

During the manual cleaning period, 333 duodenoscope cultures of eight duodenoscopes were collected; during the AT period, 100 cultures were collected. Pre-introduction of the AT, the contamination rate with MGO was 21.6%, which fell to 16% post-introduction (risk difference: -5.6%, upper bound 90% confidence interval [CI] 6.8%). For gut bacteria, the contamination rate decreased from 14.4% to 9% (risk difference: -5.4%, upper bound 90% CI 3.9%), indicating non-inferiority.

Conclusions

AT reduced the contamination rate with MGO, but non-inferiority was not demonstrated. For gut bacteria, AT was non-inferior to manual cleaning. These results are promising. However, future studies should confirm these findings in larger samples and explore other advantages of using the AT in duodenoscope cleaning.

It's All About the Bubbles: Assessing the Effects of Simethicone on Safety and Efficacy During Colonoscopy

BACKGROUND

Theoretical infection concerns prompted national Department of Veterans Affairs guidance prohibiting simethicone use in colonoscope reservoirs on January 1, 2024.

AIMS

We sought to determine if reservoir simethicone is associated with post-procedure infection and impact on procedure time, sedation usage, and adenoma detection rate.

METHODS

We conducted a retrospective cohort study of all-comers undergoing colonoscopy at Houston's Veterans Affairs hospital during September 1-30, 2023 (reservoir simethicone) and April 1-30, 2024 (aliquots administered on request [channel simethicone]). Primary outcomes were mean withdrawal and cecal intubation times. Secondary outcomes were adenoma detection rate, post-procedure 30-day infection rate, and sedation usage. We adjusted for covariates and used linear regression to determine significant predictors for mean withdrawal and intubation times.

RESULTS

Of 446 total colonoscopies, 211 used reservoir simethicone (47.3%) and 235 (52.7%) used channel simethicone. Mean intubation time was 8.3 min [SD ± 6.5] in the reservoir group and 9.9 min [SD ± 8.4] in the channel group (p = 0.03). Mean withdrawal time was 17.4 min [SD ± 10.2] in the reservoir group and 20.9 min [SD ± 11.9] in the channel group (p = < 0.01). Reservoir group procedures required less midazolam (p = 0.01) and fentanyl (p = 0.02). Post-operative infection (n = 1 vs n = 0; p = 0.47) and adenoma detection rate (p = 0.92) differences were not significant.

CONCLUSIONS

Reservoir simethicone was significantly associated with shorter intubation and withdrawal times and lower sedation usage, even after adjusting for covariates, suggesting increased efficiency with comparable infection risk.

A prospective, quasi-experimental study on the efficacy of a novel double-headed endoscope cleaning brush for cleaning flexible endoscopes

BACKGROUND

The most important step in endoscope retreatment is careful manual cleaning before disinfection. Selecting the proper brushes is critical to disinfection. The study investigated the effectiveness of a novel double-headed disposable brush for cleaning flexible gastrointestinal endoscopes.

METHODS

This prospective, quasi-experimental study included endoscopes used in a first-class hospital between January 2020 and August 2021. The primary outcome was the change in the amount of bacteria determined using the relative light unit (RLU) value of adenosine triphosphate (ATP) fluorescence.

RESULTS

A total of 267 endoscopes (131 double-headed brushes and 136 conventional ones) were included. The changes in RLU values of the ATP detection before and after brushing in the double-headed group were significantly higher than in the conventional group (ΔRLU, 116 (55, 251) vs. 76 (26, 181), P = 0.001). Similar results were observed in the subgroup analysis of colonoscopes, especially those with a 3.8-mm channel (ΔRLU, 115 (34, 265) vs. 52 (19, 199), P = 0.007), but not for gastroscopes (P = 0.363). Positive bacterial culture rates were higher in the double-headed/nylon brush end and double-headed/non-woven fabric end than in the single-headed brush (40.5% and 70.2% vs. 33.1%, P < 0.001).

DISCUSSION

The results indicated the advantage of the novel double-headed disposable brush for flexible endoscope cleaning, and the nylon brush end may explain the advantage.

CONCLUSION

The cleaning effect of the novel double-headed disposable brush for the flexible endoscope was better than the conventional one.

TRIAL REGISTRATION

Not applicable.

Ripple Effect: Safety, Cost, and Environmental Concerns of Using Sterile Water in Endoscopy

The gastroenterology societies are committed to reducing the carbon footprint of endoscopies and hence, re-examining waste-generating practices. One such practice is the recommendation to use sterile water during endoscopy for endoscopy lens cleaning and colon irrigation. We critically reviewed all published medical literature and guidelines on the safety of the type of water used in endoscopy. We calculated the cradle-to-grave carbon footprint of a 1-L sterile water bottle and compared it to published studies on bottled drinking water. Guidelines recommending sterile water during endoscopy are based on limited evidence and mostly expert opinions. Referenced studies utilize care protocols that are not practiced. There is also considerable cross-referencing of review articles and guidelines. Two clinical studies directly comparing tap and sterile water in gastrointestinal endoscopy found tap water to be a safe and practical cost-saving alternative to sterile water. The calculated carbon footprint of bottled sterile water is 575 g CO2 equivalent. No direct evidence supports the recommendation and widespread use of sterile water during gastrointestinal endoscopy procedures. It contributes to health-care waste and climate change and is costly. We recommend tap water be used to fill sterile water bottles until evidence shows the need for alternative practice. It would be prudent to re-evaluate guidelines and write new ones that consider harm to the environment and society in the provision of care to patients, especially when the intervention may be more harmful than the risk it aims to address.

Efficacy of spray flushing in the reprocessing of flexible endoscopes

This article comments on the article by Du et al, who conducted a randomized controlled trial aiming at evaluating the effectiveness of a novel spray flushing system in cleaning flexible endoscopes while minimizing damage to the working channels. We share our perspective on the importance of improving endoscope reprocessing methods. The findings highlight the spray flushing system's capacity to improve cleaning efficacy while minimizing damage, suggesting that it might be important in enhancing endoscope reprocessing procedures.

Impact of duodenoscope reprocessing factors on duodenoscope contamination: a retrospective observational study

BACKGROUND

Despite adherence to reprocessing protocols, duodenoscopes frequently remain contaminated, highlighting significant knowledge gaps in reprocessing efficiency.

AIM

To identify risk factors in duodenoscope reprocessing procedures affecting contamination rates.

METHODS

Cultures from Pentax ED34-i10T2 duodenoscopes collected between February 2022 and December 2023 were included. Contamination was determined by the presence of micro-organisms of gut or oral origin (MGO). Data on duodenoscope use, reprocessing lead times and personnel were retrieved from electronic medical records. Risk factors were derived from reprocessing guidelines and literature. These included a delay >30 min in initiating manual cleaning, manual cleaning duration of ≤5 min, drying time <90 min, personnel reprocessing frequency, and storage exceeding seven days. A logistic mixed-effects model evaluated these factors' impact on duodenoscope contamination.

FINDINGS

Out of 307 duodenoscope cultures, 58 (18.9%) were contaminated with MGO. Throughout the study period, the duodenoscopes underwent 1296 reprocessing cycles. Manual cleaning times of ≤5 min significantly increased contamination odds (adjusted odds ratio (aOR): 1.61; 95% confidence interval (CI): 1.10-2.34; P = 0.01). Increased usage of a duodenoscope was associated with reduced odds of contamination (aOR: 0.80; 95% CI: 0.64-0.995; P = 0.045). Other studied risks showed no clear association with contamination rates.

CONCLUSION

Manual cleaning times of ≤5 min increased the odds of contamination with MGO. Delays in reprocessing initiation and incomplete drying, traditionally considered as risk factors, were not associated with an increased risk of contamination in this study. Future research should explore whether enhanced surveillance of reprocessing times can mitigate duodenoscope contamination.

Current management status of cleaning and disinfection for gastrointestinal endoscopy: a meta-analysis

Objective This study aimed to evaluate the current status of cleaning and disinfection management for digestive endoscopy, provide data for standardization processing techniques, and improve the quality of cleaning and disinfection. Methods Two reviewers independently and comprehensively searched the PubMed, Cochrane Library, EMBASE, Web of Science, CNKI, Wanfang, and CBM databases on February 1, 2023. The inclusion and exclusion criteria were strictly followed during the literature survey and data extraction. All observational studies detailing the current cleaning and disinfection management status for digestive endoscopy in hospitals were included. Meta-analysis was performed using STATA 16.0 software. Results After removing different articles, the meta-analysis finally included 54 articles associated with multiple countries. The authors favor auditing staffers to confirm compliance with guidelines. The meta-analysis results indicated a configuration rate of 76% (95% CI: 68-83%) for separate rooms designated for reprocessing; 79% (95% CI: 72-84%) for reprocessing rooms with adequate ventilation; 30% (95% CI: 24-36%) for automated endoscope washer-disinfectors; 68% (95% CI: 55-81%) for complete protective equipment usage; 90% (95% CI: 83-95%) for the configuration rate of endoscope and accessory storage cabinets; 50% (95% CI: 38-61%) for changing enzymatic-type detergents after each use; 51% (95% CI: 30-71%) for the use of purified or sterilized water for final rinsing; 80% (95% CI: 70-88%) for monitoring disinfectant concentration; 87% (95% CI: 80-93%) for microbial monitoring; and 44% (95% CI: 26-62%) for the usage of protective equipment. Conclusion The configuration of the automated endoscope washer-disinfector, non-standard cleaning and disinfection procedures, and a lack of occupational protection awareness among personnel responsible for cleaning and disinfecting digestive endoscopy were all apparent issues. It was suggested that all departments enhance their levels of management and supervision, standardize reprocessing procedures and quality control details, upgrade hardware facilities and spatial layouts, reinforce personnel training, and increase staff awareness of nosocomial infection risks.

Investigation of failure of flexible GI endoscope disinfection because of Burkholderia cepacia contamination in irrigation tubing

BACKGROUND AND AIMS

This study aims to identify the cause of disinfection failure for multiple flexible GI endoscopes and to enhance the cleaning and disinfection procedures.

METHODS

Samples from the endoscopy devices, surrounding objects, cleaning water, automatic sterilizer, and integrated endoscopic washing workstation in a Digestive Endoscopy Center were collected and analyzed for microbial contamination and DNA/gene contents between May and July 2021.

RESULTS

The sample analysis revealed that the sink irrigation tubing of the washing workstation was contaminated with Burkholderia cepacia. After effective disinfection measures, the B cepacia detection in the disinfected endoscope dropped from 13.23% to 0% (P = .041). The presence of B cepacia was confirmed through homology search and gene sequencing.

CONCLUSIONS

The primary reason for endoscope disinfection failure is the contamination of the sink irrigation tubing by the B cepacia bacteria. These findings emphasize the need for thorough cleaning of irrigation tubing in integrated endoscopic washing workstations, which is generally neglected in routine maintenance.

A multicenter study comparing the bacterial reduction on flexible endoscopes without a working channel between UV-C light disinfection versus standard endoscope Washer Disinfection: a randomized controlled trial

BACKGROUND

To prevent cross-contamination between patients, adequate reprocessing is necessary when using flexible endoscopes (FEs) without a working channel. The current reprocessing process using an Endoscope Washer Disinfector (EWD) is time-consuming. Ultraviolet light group C (UV-C) exposition is an alternative and fast disinfection method and has previously been shown to adequately reduce Colony Forming Units (CFUs) on FEs without a working channel. The objective of this study was to examine whether UV-C light is as effective in reducing CFUs on contaminated FEs without a working channel compared to the EWD.

METHODS

FEs without a working channel were collected in three different Otorhinolaryngology Departments in the Netherlands. After pharyngolaryngoscopy, a manual pre-cleaning with tap water was performed and a culture was collected by rolling the distal 8-10 cm of the FE over an agar plate. Next, the FE was randomly assigned to be disinfected with UV-C light (D60) or the EWD (gold standard). After disinfection, another culture was taken. The primary outcome was microbiological contamination, defined by Colony Forming Units (CFU).

RESULTS

600 FEs without a working channel were randomized. After clinical use and manual pre-cleaning, 239/300 (79.7%) FEs in the UV-C group and 262/300 (87.3%) FEs in the EWD group were contaminated (i.e., > 0 CFU). FEs without culture confirmed contamination were excluded from further analysis. After UV-C light disinfection, 195/239 (81.6%) FEs showed 0 CFUs, compared to 187/262 (71.4%) FEs disinfected with the EWD (p < 0.01). A multivariate logistics regression analysis showed an increased odds of 0 CFUs when using UV-C light (OR 1.83, 95% CI 1.19-2.79; p < 0.01), conditional on participating hospitals and types of FE.

CONCLUSIONS

UV-C light disinfection of FEs without a working channel appears more effective in reducing CFUs compared to the EWD and might be a good alternative disinfection method.

TRIAL REGISTRATION

Not applicable.

Effect of simethicone on the bactericidal efficacy of a high-level disinfectant

Introduction. Simethicone is an over-the-counter product that is frequently used by clinicians during endoscopic procedures to reduce foaming and improve visualization. Published studies have found simethicone residue on endoscopes after cleaning and disinfecting the devices as per the manufacturer's instructions. Some literature suggests that simethicone residue may reduce disinfection efficacy and increase the risk of patient infections.Gap Statement. However, there appears to be a lack of direct evidence in the literature to either disprove this or correlate simethicone presence with an increased microbial risk.Aim: Research was conducted to evaluate the in vitro impact of simethicone on disinfection efficacy.Methodology. Bacteria were grown in a microtitre plate assay in the presence of a range of simethicone concentrations and then treated with a disinfectant. Bacterial growth was assessed by spotting each microtitre well onto an agar plate.Results. The results demonstrated that, under the conditions tested, simethicone did not reduce the efficacy of Cidex ortho-phthalaldehyde disinfectant, which demonstrated at least a 6-log unit reduction in bacterial viability. Additional experiments showed that direct exposure to 66 mg ml-1 of simethicone reduced bacterial viability.Conclusion. These results indicate that simethicone may not reduce the bactericidal efficacy of disinfectant during reprocessing, under certain conditions.

Efficacy of spray flushing in the reprocessing of flexible endoscopes: A randomized controlled trial

BACKGROUND

Commonly used cleaning brushes in the reprocessing of flexible endoscopes often cause damage within the working channels.

AIM

To develop a spray flushing system to achieving effective cleaning of the working channels while minimizing damage.

METHODS

This prospective study included 60 used endoscopes and 60 Teflon tubes randomly divided into a control group (n = 30) and an experimental group (n = 30). The material of Teflon tubes was the same as that of the endoscope working channel. Endoscopes in the control group were manually cleaned using traditional cleaning brushes, while those in the experimental group were cleaned using the newly developed spray flushing system. ATP levels, cleanliness, and microbiological testing of the working channels were measured. Additionally, Teflon tubes in the control group underwent 500 passes with a cleaning brush, while those in the experimental group were subjected to the spray flushing system, and channel damage was evaluated.

RESULTS

The ATP levels (RLU) in the two groups were 32.5 (13-66) and 26 (16-40), respectively (P > 0.05). Cleanliness scores were 1.5 (1-2) and 1 (1-2), respectively (P > 0.05). Debris was found in 73.3% of the control group, which was significantly higher than 46.7% in the experimental group (P < 0.05). Microbiological tests for both groups yielded negative results. Teflon tube damage in the control group was rated at 4 (4-5.25), which was significantly higher than in the experimental group 4 (3-4) (P < 0.01).

CONCLUSION

The spray flushing system demonstrated superior efficacy in removing debris and resulted in less damage to the endoscope working channels compared with traditional cleaning brushes.

Endoscope channel drying, storage, and conditions after reprocessing: How safe are they in clinical practice?

INTRODUCTION AND AIMS

Adequate drying and proper storage of flexible endoscopes are essential for maintaining quality in their reprocessing. The aim of the present study was to evaluate the drying stages, storage, and channel conditions of endoscopes through borescope inspection.

MATERIAL AND METHODS

The personnel responsible for endoscope reprocessing were interviewed. Storage conditions at 10 endoscopy facilities were inspected and an internal examination of the channels and ports of the stored equipment was carried out, utilizing a borescope. A total of 74 stored endoscope channels were evaluated.

RESULTS

Only 10% of the facilities inspected utilized transport cases for storage and only 10% had rooms exclusively used for storage. Sixty percent of the facilities did not perform any shelf-life control. All the channels evaluated were scratched and fluids were present on 69% of them.

CONCLUSIONS

Endoscope reprocessing can be improved through the implementation of drying and storage control and validation tools, as well as the use of borescopes and periodic clinical audits.

Fluid retention in endoscopes: A real-world study on drying effectiveness

BACKGROUND

Outbreaks linked to inadequate endoscope drying have infected numerous patients, and current standards and guidelines recommend at least 10 minutes of forced air for drying channels. This study evaluated a new forced-air drying system (FADS) for endoscopes.

METHODS

Drying was assessed using droplet detection cards; visual inspection of air/water connectors, suction connectors, and distal ends; and borescope examinations of endoscope interiors. Assessments were performed after automated endoscope reprocessor (AER) alcohol flush and air purge cycles and after 10-minute FADS cycles.

RESULTS

Researchers evaluated drying during encounters with 22 gastroscopes and 20 colonoscopes. After default AER alcohol and air purge cycles, 100% (42/42) of endoscopes were still wet. Substantial fluid emerged from distal ends during the first 15 seconds of the FADS cycle, and droplets also emerged from air/water and suction connectors. Following FADS cycle completion, 100% (42/42) were dry, with no retained fluid detected by any of the assessment methods.

CONCLUSIONS

Multiple endoscope ports and channels remained wet after AER cycles intended to aid in drying but were dry after the FADS cycle. This study reinforced the need to evaluate the effectiveness of current drying practices and illustrated the use of practical tools in a real-world setting.

Ecogastroenterology: cultivating sustainable clinical excellence in an environmentally conscious landscape

Gastrointestinal practices, especially endoscopy, have a substantial environmental impact, marked by notable greenhouse gas emissions and waste generation. As the world struggles with climate change, there emerges a pressing need to re-evaluate and reform the environmental footprint within gastrointestinal medicine. The challenge lies in finding a harmonious balance between ensuring clinical effectiveness and upholding environmental responsibility. This task involves recognising that the most significant reduction in the carbon footprint of endoscopy is achieved by avoiding unnecessary procedures; addressing the use of single-use endoscopes and accessories; and extending beyond the procedural suites to include clinics, virtual care, and conferences, among other aspects of gastrointestinal practice. The emerging digital realm in health care is crucial, given the potential environmental advantages of virtual gastroenterological care. Through an in-depth analysis, this review presents a path towards sustainable gastrointestinal practices, emphasising integrated strategies that prioritise both patient care and environmental stewardship.

Increasing Antibiotic-Resistant Infections With Inpatient Endoscopic Retrograde Cholangioscopies (ERCP) Is Associated With Higher Mortality in the United States: A Cross-sectional Cohort Study

GOALS

This study aims to investigate associated mortality with inpatient endoscopic retrograde cholangiopancreatography (ERCP) with and without resistant infections. The co-primary objective compares frequencies of inpatient ERCP with resistant infections to overall hospitalizations with resistant infections.

BACKGROUND

The risks of inpatient antibiotic-resistant organisms are known, but the associated mortality for inpatient ERCP is unknown. We aim to use a national database of hospitalizations and procedures to understand trends and mortality for patients with antibiotic-resistant infections during inpatient ERCP.

STUDY

The largest publicly available all-payer inpatient database in the United States (National Inpatient Sample) was used to identify hospitalizations associated with ERCPs and antibiotic-resistant infections for MRSA, VRE, ESBL, and MDRO. National estimates were generated, frequencies were compared across years, and multivariate regression for mortality was performed.

RESULTS

From 2017 to 2020, national weighted estimates of 835,540 inpatient ERCPs were generated, and 11,440 ERCPs had coincident resistant infections. Overall resistant infection, MRSA, VRE, and MDRO identified at the same hospitalization of inpatient ERCPs were associated with higher mortality (OR CI(95%): Overall: 2.2(1.77-2.88), MRSA: 1.90 (1.34-2.69), VRE: 3.53 (2.16-5.76), and MDRO: 2.52 (1.39-4.55)). While overall hospitalizations with resistant infections have been decreasing annually, there has been a yearly increase in admissions requiring ERCPs with simultaneous resistant infections ( P =0.001-0.013), as well as infections with VRE, ESBL, and MDRO ( P =0.001-0.016). Required Research Practices for Studies Using the NIS scoring was 0, or the most optimal.

CONCLUSIONS

Inpatient ERCPs have increasing coincident resistant infections and are associated with higher mortality. These rising infections during ERCP highlight the importance of endoscopy suite protocols and endoscopic infection control devices.

AGA Clinical Practice Update on High-Quality Upper Endoscopy: Expert Review

DESCRIPTION

The purpose of this Clinical Practice Update (CPU) Expert Review is to provide clinicians with guidance on best practices for performing a high-quality upper endoscopic exam.

METHODS

The best practice advice statements presented herein were developed from a combination of available evidence from published literature, guidelines, and consensus-based expert opinion. No formal rating of the strength or quality of the evidence was carried out, which aligns with standard processes for American Gastroenterological Association (AGA) Institute CPUs. These statements are meant to provide practical, timely advice to clinicians practicing in the United States. This Expert Review was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates (CPU) Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Clinical Gastroenterology & Hepatology. BEST PRACTICE ADVICE 1: Endoscopists should ensure that upper endoscopy is being performed for an appropriate indication and that informed consent clearly explaining the risks, benefits, alternatives, sedation plan, and potential diagnostic and therapeutic interventions is obtained. These elements should be documented by the endoscopist before the procedure. BEST PRACTICE ADVICE 2: Endoscopists should ensure that adequate visualization of the upper gastrointestinal mucosa, using mucosal cleansing and insufflation as necessary, is achieved and documented. BEST PRACTICE ADVICE 3: A high-definition white-light endoscopy system should be used for upper endoscopy instead of a standard-definition white-light endoscopy system whenever possible. The endoscope used for the procedure should be documented in the procedure note. BEST PRACTICE ADVICE 4: Image enhancement technologies should be used during the upper endoscopic examination to improve the diagnostic yield for preneoplasia and neoplasia. Suspicious areas should be clearly described, photodocumented, and biopsied separately. BEST PRACTICE ADVICE 5: Endoscopists should spend sufficient time carefully inspecting the foregut mucosa in an anterograde and retroflexed view to improve the detection and characterization of abnormalities. BEST PRACTICE ADVICE 6: Endoscopists should document any abnormalities noted on upper endoscopy using established classifications and standard terminology whenever possible. BEST PRACTICE ADVICE 7: Endoscopists should perform biopsies for the evaluation and management of foregut conditions using standardized biopsy protocols. BEST PRACTICE ADVICE 8: Endoscopists should provide patients with management recommendations based on the specific endoscopic findings (eg, peptic ulcer disease, erosive esophagitis), and this should be documented in the medical record. If recommendations are contingent upon histopathology results (eg, H pylori infection, Barrett's esophagus), then endoscopists should document that appropriate guidance will be provided after results are available. BEST PRACTICE ADVICE 9: Endoscopists should document whether subsequent surveillance endoscopy is indicated and, if so, provide appropriate surveillance intervals. If the determination of surveillance is contingent on histopathology results, then endoscopists should document that surveillance intervals will be suggested after results are available.

Recommendations and guidelines for endoscope reprocessing: Current position statement of digestive endoscopic society of Taiwan

Reprocessing of gastrointestinal (GI) endoscopes and accessories is an essential part of patient safety and quality control in GI endoscopy centers. However, current endoscopic reprocessing guidelines or procedures are not adequate to ensure patient-safe endoscopy. Approximately 5.4 % of the clinically used duodenoscopes remain contaminated with high-concern microorganisms. Thus, the Digestive Endoscopy Society of Taiwan (DEST) sets standards for the reprocessing of GI endoscopes and accessories in endoscopy centers. DEST organized a task force working group using the guideline-revision process. These guidelines contain principles and instructions of step-by-step for endoscope reprocessing. The updated guidelines were established after a thorough review of the existing global and local guidelines, systematic reviews, and health technology assessments of clinical effectiveness. This guideline aims to provide detailed recommendations for endoscope reprocessing to ensure adequate quality control in endoscopy centers.

Optical illusions: The vital importance of instructions for use and intentionally approaching eye device processing

BACKGROUND

The purpose of this process and quality improvement activity was to address opportunities identified with cleaning, disinfection, and sterilization requirements for eye devices, and implement a robust and sustainable processing system to support safe patient care.

METHODS

Through the lean 6 Sigma methodology, the evaluation of noncritical, semicritical and critical device processing was conducted. A hierarchal approach to law, regulation, manufacturer's instructions for use, evidence-based guidelines, consensus documents, facility risk assessments, policy, and procedure was conducted. Over 15 diverse clinical areas within a large health care network were assessed for utilization of ophthalmic and optometric devices, with the review of inventory for manufacturer-instructed cleaning, disinfection and sterilization compliance.

RESULTS

An interdepartmental multidisciplinary team with oversight of over 10 service lines led the implementation of point-of-use treatment, transport, high-level disinfection, sterilization, storage, and documentation based on intended use.

CONCLUSIONS

During this experience, infection Preventionists performed a vital role in supporting a highly reliable cleaning, disinfection, and sterilization process. This undertaking required a team approach to apply instructions for uses and evidence-based practice that promoted sustainability and ultimately led to supporting the prevention of health care-associated infections and patient harm.

Estimating the environmental impact of endoscopic activity at a tertiary center: a pilot study

INTRODUCTION

The growing number of endoscopic procedures, frequently requiring single-use disposable instruments, is responsible for the production of a large amount of waste. To this date, the reality of waste production at large European Gastroenterology centers is unknown. This study aimed to estimate the amount of waste due to endoscopic practice at a tertiary center in Portugal.

METHODS

We performed a prospective study to calculate the mass (in kg) of residues generated during a period of 5 working days of endoscopic practice. We included residues produced at endoscopy suites, pre and postprocedure areas and during endoscope reprocessing. Residues were categorized as non-dangerous (groups I/II), of biologic risk (group III) and specific hazardous hospital residues (group IV). The production of residues separated for recycling/valorization (paper/card and plastic) was also quantified. The volume of water used for reprocessing an endoscope was also assessed.

RESULTS

During the analyzed period, 241 endoscopic procedures were performed. A total of 443.2 kg of waste (22.6 kg from groups I/II, 266.9 kg from group III and 3.9 kg from group IV) were produced, most from group III (75%). For each endoscopic procedure, 1.8 kg of waste was generated. Of the total waste mass, 17.8% was separated for recycling/valorization. A volume of 55L of water was required for reprocessing one endoscope.

CONCLUSION

Each endoscopic procedure generated a significant amount of waste and water consumption during reprocessing. These real-life analyses are a pivotal step before implementing effective measures to improve resource utilization and more sustainable practices.

Is ultraviolet light disinfection fit to be the future standard for the disinfection of flexible endoscopes without a working channel?

OBJECTIVE

To investigate colony-forming unit (CFU) reduction on contaminated flexible endoscopes (FEs) without a working channel after UV-C light disinfection, compared to the current disinfection method with the endoscope washer disinfector (EWD).

DESIGN, SETTING AND PARTICIPANTS

After pharyngolaryngoscopy, a manual pre-cleaning with tap water was performed. A culture was then collected by rolling the distal 8-10 cm of the FE over an Agar plate. The FE was disinfected using the D60 (60-s disinfection process with UV-C light) or the EWD (gold standard reprocessing process with water and chemicals). Another culture was then taken. After incubation, a CFU count was performed.

RESULTS

A total of 200 FEs without a working channel were divided equally between the two disinfection groups. After clinical use and manual pre-cleaning, 84 of the 100 (84.0%) (UV-C light group) and 79 of the 100 (79.0%) (EWD) FEs were contaminated with at least 1 CFU. FEs that showed no contamination after use were excluded from further analysis. After disinfection with UV-C light, 72 (85.7%) FEs showed no contamination (i.e., 0 CFUs) versus 66 (83.5%) FEs after reprocessing with the EWD.

CONCLUSION

There is no difference in CFUs reduction on contaminated FEs without a working channel between UV-C light disinfection and the current gold standard, the EWD.

Effect of a disposable endoscope precleaning kit in the cleaning procedure of gastrointestinal endoscope: A multi-center observational study

BACKGROUND

Precleaning is a key step in endoscopic reprocessing.

AIM

To develop an effective and economic endoscope cleaning method by using a disposable endoscope bedside precleaning kit.

METHODS

Altogether, 228 used gastrointestinal endoscopes were selected from five high-volume endoscopy units and precleaned by a traditional precleaning bucket (group T) or a disposable endoscope bedside precleaning kit (group D). Each group was further subdivided based on the replacement frequency of the cleaning solution, which was replaced every time in subgroups T1 and D1 and every several times in subgroups Ts and Ds. The adenosine triphosphate (ATP) level and residual proteins were measured three times: Before and after precleaning and after manual cleaning.

RESULTS

After precleaning, the precleaning kit significantly reduced the ATP levels (P = 0.034) and has a more stable ATP clearance rate than the traditional precleaning bucket. The precleaning kit also saved a quarter of the cost of enzymatic detergent used during the precleaning process. After manual cleaning, the ATP levels were also significantly lower in the precleaning kit group than in the traditional precleaning bucket group (P < 0.05). Meanwhile, the number of uses of the cleaning solution (up to four times) has no significant impact on the cleaning effect (P > 0.05).

CONCLUSION

Considering its economic cost and cleaning effect, the use of a disposable endoscope bedside precleaning kit can be an optimal option in the precleaning stage with the cleaning solution being replaced several times in the manual cleaning stage.

Promoting Research that Supports High-Quality Gastrointestinal Endoscopy in Children

PURPOSE OF REVIEW

Defining and measuring the quality of endoscopic care is a key component of performing gastrointestinal endoscopy in children. The purpose of this review is to discuss quality metrics for pediatric gastrointestinal endoscopy and identify where additional research is needed.

RECENT FINDINGS

Pediatric-specific standards and indicators were recently defined by the international Pediatric Endoscopy Quality Improvement Network (PEnQuIN) working group through a rigorous guideline consensus process. Although the aim of these guidelines is to facilitate best practices for safe and high-quality gastrointestinal endoscopy in children, they highlight the pressing need to expand upon the body of evidence supporting these standards and indicators as predictors of clinically relevant outcomes. In this review, we propose and discuss ideas for several high-yield research topics to engage pediatric endoscopists and promote best practices in pediatric endoscopy.

What Are the Ready-to-Use Endoscope Channels Hiding?: Unraveling the Risks of Safe Reuse

Contamination due to failures or omissions in the reprocessing steps of gastrointestinal endoscopes is common in clinical practice. Ensuring the proper execution of each step is a challenge for reprocessing personnel. This cross-sectional study was conducted in an endoscopy setting between March and May 2021. We performed interviews about reprocessing practices, analyzed the life history of the equipment, and performed inspections through a borescope video of gastrointestinal endoscope channels that were stored and ready for use. A borescope is a complementary tool used to validate endoscope reprocessing, evaluate the internal visualization of channels, and identify changes that can compromise the safety of its use, which are often not detected in the leak test. Thirteen biopsy channels from stored gastrointestinal endoscopes were inspected. We found that 85% had stains and grooves, 69% contained moisture, and 46% had debris. There was at least one noncompliance issue in all of the channels inspected.

Evaluation of a novel disposable esophagogastroduodenoscopy system in emergency, bedside, and intraoperative settings: Pilot study (with videos)

OBJECTIVES

The disposable esophagogastroduodenoscopy (EGD) system is a novel endoscopic device which is highly portable and is designed to eliminate the risk of cross-infection caused by reusable EGD. This study aimed to investigate the feasibility and safety of disposable EGD in emergency, bedside, and intraoperative settings.

METHODS

This was a prospective, single-center, noncomparative study. Disposable EGD was used for emergency, bedside, and intraoperative endoscopies in 30 patients. The primary end-point was the technical success rate of the disposable EGD. Secondary end-points included technical performance indicators including clinical operability, image quality score, procedure time, the incidence of device malfunction and/or failure, and the incidence of adverse events.

RESULTS

A total of 30 patients underwent diagnosis and/or treatment with disposable EGD. Therapeutic EGD was performed on 13/30 patients, including hemostasis (n = 3), foreign body retrieval (n = 6), nasoenteric tube placement (n = 3), and percutaneous endoscopic gastrostomy (n = 1). The technical success rate was 100%: all procedures and indicated interventions were completed without changing to a conventional upper endoscope. The mean image quality score obtained immediately after procedure completion was 3.72 ± 0.56. The mean (± SD) procedure time was 7.4 (± 7.6) min. There were no device malfunctions or failures, device-related adverse events, or overall adverse events.

CONCLUSION

The disposable EGD may be a feasible alternative to the traditional EGD in emergency, bedside, and intraoperative settings. Preliminary data show that it is a safe and effective tool for diagnosis and treatment in emergency and bedside upper gastrointestinal cases.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (Trial ID: ChiCTR2100051452, https://www.chictr.org.cn/showprojen.aspx?proj=134284).

Reprocessing semicritical items: An overview and an update on the shift from HLD to sterilization for endoscopes

BACKGROUND

Semicritical medical devices are defined as items that come into contact with mucous membranes or nonintact skin (e.g., gastrointestinal endoscopes, endocavitary probes). Such medical devices require minimally high-level disinfection.

METHODS

Analyze the methods used to reprocess semicritical medical devices and identify methods and new technologies to reduce the risk of infection.

RESULTS

The reprocessing methods for semicritical medical devices is described as well as a shift from high-level disinfection to sterilization for lumened endoscopes.

CONCLUSIONS

Strict adherence to current guidelines and transition to sterilization for endoscopes is required as more outbreaks have been linked to inadequately disinfected endoscopes and other semicritical items than any other reusable medical devices.

A water-soluble alternative to simethicone for gastrointestinal endoscopy: Results of a clinical trial

During endoscopy, simethicone defoaming agents are commonly used to improve visualization, but they leave residues and impact drying. This clinical trial involved patients undergoing colonoscopy procedures with substantial bubbles that impeded mucosal wall visibility. As an alternative to simethicone, investigators evaluated a water-soluble, ginger-based gastrointestinal supplement (GI-Ease) that did not contain sugars, thickeners, or binding agents. In 112/114 cases (98%), the bubbles were reduced sufficiently to allow visualization of the gastrointestinal tract, with no adverse events.

Significant increased bacterial contamination with endoscope overnight and weekend storage times

BACKGROUND AND AIM

Forced-air drying (FAD) cabinets are recommended for storage of reprocessed endoscopes, but financial constraints prevent their universal application. The study aimed to determine bacterial contamination in flexible gastroscopes (FG) channels after storage, in a cabinet with filtered air and UV lights, but without FAD.

METHODS

Eight FG in clinical use in an endoscopy service of a large Brazilian hospital were sampled: immediately "Time zero" (N = 50), 12 h "Time 1" (N = 25), and 60 h "Time 2" (N = 25) after reprocessing. Following a flush-brush-flush of channels, 40-mL sterile water and 3 cm of the brush were collected. Each sample was divided, filtered onto two 0.22-μm membranes, and incubated in media without or with disinfectant neutralizer. Automated method was used for identification and antibiotic resistance test of isolated bacteria.

RESULTS

Bacterial contamination in times "1" and "2" was 5.9 and 16.1 times greater than that of "Time zero," respectively. Number of positive cultures in media with and without neutralizer was similar at times "1" and "2," while media with neutralizer produced more positive cultures at "Time zero." Most bacteria isolated at "Time 2" were Gram-negative rods (52.3%) and showed resistance to one or more antibiotics (65%).

CONCLUSION

Bacterial contamination was detected on reprocessed FG stored in non-FAD cabinets overnight (12 h) and increased with longer storage time (60 h). The contamination source is likely to be bacteria in biofilm which multiply in the absence of FAD. Evidence-based criteria should be available for storage time according to the cabinet available.

Costs of purchase, maintenance, microbiological control, and reprocessing of a reusable duodenoscope

Background and study aims The costs of reusable endoscope reprocessing have been evaluated, yet external validity of the findings remains challenging. The aim of this study was to assess the costs of purchase, maintenance, microbiological control, and reprocessing of a reusable duodenoscope per endoscopic retrograde cholangiopancreatography (ERCP) in France. Study findings exclude the costs of infection, downtime due to breakdown, reprocessing single-use material disposal, and device disposal, all of which should also be considered. Materials and methods The study encompassed both observational and theoretical approaches. Observational data were collected in four hospitals, from December 2019 to December 2020, with an ad hoc survey, based on 2016 and 2018 national guidelines for duodenoscope reprocessing. Costs were modeled, using the same guidelines, assuming a mean workload of 223 ERCP/duodenoscope/year. Results The mean observed cost of purchase, maintenance, microbiological control, reprocessing (human resources and consumables), and overhead (additional 35%) with a reusable duodenoscope was €80.23 (standard deviation €3.77) per ERCP. The corresponding mean theoretical cost was €182.71 for manual reprocessing without endoscope drying cabinet (EDC), €191.36 for manual reprocessing with EDC, €235.25 for automated endoscope reprocessing (AER) without EDC, and €253.62 for AER with EDC. Conclusions Because procedures, equipment, volume activity, number of duodenoscopes, human resources, and internal work organizations are hospital-dependent, observed costs varied between hospitals. Theoretical costs were higher than observed costs, showing that the theoretical approach is not sufficient. Hypotheses to explain the difference between the two approaches include failing to measure some costs in the survey and challenges in guideline implementation.

Effect of an automated flexible endoscope channel brushing system on improving reprocessing quality: a randomized controlled study

BACKGROUND

Qualified reprocessing, of which meticulous channel brushing is the most crucial step, is essential for prevention and control of endoscopy-associated infections. However, channel brushing is often omitted in practice. This study aimed to evaluate the effect of an automated flexible endoscope channel brushing system (AECBS) on improving the quality of endoscope reprocessing.

METHODS

This prospective, randomized controlled study was conducted between 24 November 2021 and 22 January 2022 at Renmin Hospital of Wuhan University, China. Eligible endoscopes were randomly allocated to the auto group (channels brushed by AECBS) or the manual group (channels brushed manually), with sampling and culturing after high-level disinfection and drying. The primary end point was the proportion of endoscopes with positive cultures.

RESULTS

204 endoscopes in the auto group and 205 in the manual group were analyzed. The proportion of endoscopes with positive cultures was significantly lower in the auto group (15.2 % [95 %CI 10.7 %-21.0 %]) than in the manual group (23.4 % [95 %CI 17.9 %-29.9 %]).

CONCLUSIONS

AECBS could effectively reduce bioburden and improve reprocessing quality of gastroscopes and colonoscopes. AECBS has the potential to replace manual brushing and lower the risk of endoscopy-associated infections, providing a new option for the optimization of reprocessing.

Alcohol flush does not aid in endoscope channel drying but may serve as an adjunctive microbiocidal measure: A new take on an old assumption

BACKGROUND

Alcohol is perceived to aid flexible endoscope channel drying, however we previously showed alcohol increased the time required to dry some channels with forced air versus water alone. Yet, alcohol may prevent microorganism outgrowth during storage. Drying endoscope channels has been shown to prevent outgrowth, but it is unknown if incomplete drying (<10 µL remaining) provides similar protection.

METHODS

Endoscope channel test articles were used to determine the efficacy of 70%-30% alcohol flush for prevention of Pseudomonas aeruginosa outgrowth and drying efficiency. For non-alcohol flushed channels, the impact of forced air drying on outgrowth of P. aeruginosa was determined.

RESULTS

Alcohol flush (70%-30%) prevented outgrowth with little to no recovery of P. aeruginosa during ambient storage. 70% alcohol increased channel drying time by 1.5 or 3-fold compared to 50% alcohol or water, respectively. Forced air drying of non-alcohol flushed channels greatly reduced the initial contamination level and prevented outgrowth. Incomplete drying of contaminated channels was akin to no application of forced air. Applying forced air for more time than necessary to remove residual liquid did not completely eliminate the low level recovery of P. aeruginosa.

CONCLUSIONS

Flushing with reduced concentrations of alcohol may provide a strategy to prevent microbial outgrowth while reducing drying time.

A review of Spaulding's classification system for effective cleaning, disinfection and sterilization of reusable medical devices: Viewed through a modern-day lens that will inform and enable future sustainability

Despite advances in medicine and innovations in many underpinning fields including disease prevention and control, the Spaulding classification system, originally proposed in 1957, remains widely used for defining the disinfection and sterilization of contaminated re-usable medical devices and surgical instruments. Screening PubMed and Scopus databases using a PRISMA guiding framework generated 272 relevant publications that were used in this review. Findings revealed that there is a need to evolve how medical devices are designed, and processed by cleaning, disinfection (and/or sterilization) to mitigate patient risks, including acquiring an infection. This Spaulding Classification remains in use as it is logical, easily applied and understood by users (microbiologists, epidemiologists, manufacturers, industry) and by regulators. However, substantial changes have occurred over the past 65 years that challenge interpretation and application of this system that includes inter alia emergence of new pathogens (viruses, mycobacteria, protozoa, fungi), a greater understanding of innate and adaptive microbial tolerance to disinfection, toxicity risks, increased number of vulnerable patients and associated patient procedures, and greater complexity in design and use of medical devices. Common cited examples include endoscopes that enable non- or minimal invasive procedures but are highly sophisticated with various types of materials (polymers, electronic components etc), long narrow channels, right angle and heat-sensitive components and various accessories (e.g., values) that can be contaminated with high levels of microbial bioburden and patient tissues after use. Contaminated flexible duodenoscopes have been a source of several significant infection outbreaks, where at least 9 reported cases were caused by multidrug resistant organisms [MDROs] with no obvious breach in processing detected. Despite this, there is evidence of the lack of attention to cleaning and maintenance of these devices and associated equipment. Over the last few decades there is increasing genomic evidence of innate and adaptive resistance to chemical disinfectant methods along with adaptive tolerance to environmental stresses. To reduce these risks, it has been proposed to elevate classification of higher-risk flexible endoscopes (such as duodenoscopes) from semi-critical [contact with mucous membrane and intact skin] to critical use [contact with sterile tissue and blood] that entails a transition to using low-temperature sterilization modalities instead of routinely using high-level disinfection; thus, increasing the margin of safety for endoscope processing. This timely review addresses important issues surrounding use of the Spaulding classification system to meet modern-day needs. It specifically addresses the need for automated, robust cleaning and drying methods combined with using real-time monitoring of device processing. There is a need to understand entire end-to-end processing of devices instead of adopting silo approaches that in the future will be informed by artificial intelligence and deep-learning/machine learning. For example, combinational solutions that address the formation of complex biofilms that harbour pathogenic and opportunistic microorganisms on the surfaces of processed devices. Emerging trends are addressed including future sustainability for the medical devices sector that can be enabled via a new Quintuple Helix Hub approach that combines academia, industry, healthcare, regulators, and society to unlock real world solutions.

Unlocking quality in endoscopic mucosal resection

A review of the development of the key performance metrics of endoscopic mucosal resection (EMR), learning from the experience of the establishment of widespread colonoscopy quality measurements. Potential future performance markers for both colonoscopy and EMR are also evaluated to ensure continued high quality performance is maintained with a focus service framework and predictors of patient outcome.

[A systematic analysis of nosocomial outbreaks of nosocomial infections after gastrointestinal endoscopy]

Esophagogastroduodenoscopy (EGD), endoscopic retrograde cholangiopancreatography (ERCP) and colonoscopy (CLN) come with a potential risk of pathogen transmission. Unfortunately, up to now data on the causes and the distribution of pathogens is rather sparse.We performed a systematic review of the medical literature using the Worldwide Outbreak Database, the PubMed, and Embase. We then checked so-retrieved articles for potential sources of the outbreak, the spectrum of pathogens, the attack rates, mortality and infection control measures.In total 73 outbreaks (EGD: 24, ERCP: 42; CLN: 7) got included. The corresponding attack rates were 3.5%, 7.1% and 12.8% and mortality rates were 6.3%, 12.7% and 10.0% respectively. EGD was highly associated with transmission of enterobacteria including a large proportion of multi-drug resistant strains. ERCP led primarily to transmission of non-fermenting gram-negative rods. The most frequent cause was human failure during reprocessing regardless of the type of endoscope.Staff working in the field of endoscopy should always be aware of the possibility of pathogen transmission in order to detect and terminate those events at the early most time point. Furthermore, proper ongoing education of staff involved in the reprocessing and maintenance of endoscopes is crucial. Single-use devices may be an alternative option and lower the risk of pathogen transmission, but on the downside may also increase costs and waste.

Improving mastery and retention of knowledge and complex skills among sterile processing professionals: A pilot study on borescope training and competency testing

BACKGROUND

Healthcare is shifting toward minimally invasive procedures requiring increasingly complex instruments and sophisticated processing technologies. Effective training methods are needed to ensure sterile processing professionals acquire and retain essential skills.

OBJECTIVE

This study aimed to develop and evaluate a new training model that supports mastery and retention of complex key skills.

METHODS

The model was pilot-tested with training focused on visual inspection of endoscopes. Pre- and post-training tests were administered to enhance learning during a face-to-face workshop that interspersed lectures and hands-on practice, followed by structured homework, and an online booster session. Surveys assessed satisfaction and confidence levels.

RESULTS

Mean test scores for nine certified sterile processing employees increased significantly following the workshop (41% vs. 84%, p<0.001). After the workshop, all trainees identified actionable visible defects on patient-ready endoscopes in their facilities. Test scores remained high after two months (90%), and trainees reported higher technical confidence and satisfaction levels after training.

CONCLUSIONS

This study demonstrated effectiveness and clinical relevance of a new, evidence-based model for training sterile processing professionals that incorporated pre-testing, lectures, hands-on practice, a training booster, and post-testing to enhance learning. This model may be applicable to other complex skills necessary for infection prevention and patient safety.

A Single-Blind Study Testing the Preparation Accuracy of Bedside Precleaning Solutions Used for Flexible Endoscopes

Endoscopy-related pathogen transmission may occur if microorganisms are spread from patient to patient by contaminated equipment. Effective and safe endoscope reprocessing includes bedside precleaning, mechanical cleaning, high-level disinfection, storage, and drying. The aim of this research study was to observe and report on the variation in practice regarding the use of detergent for bedside precleaning of flexible gastrointestinal endoscopes. Endoscopy nurses working in the endoscopy unit at the Princess Alexandra Hospital, Australia, prepared four samples of detergent solution as per normal routine. Twenty-nine nurses participated providing in total 116 samples. There was a significant variation in detergent concentration. The detergent concentration variated between 2.00 and 288.20 ml/L ( M = 34.55, SD = 39.21). Two samples revealed lower concentrations than required. More than 25% of the samples contained at least a 10 times higher concentration than required (>40 ml/L). Current practice of bedside precleaning of gastrointestinal endoscopes was not deemed safe or cost-effective as it did not guarantee an adequate concentration of detergent. More precise methods to establish the required concentration of the bedside precleaning solution were introduced to improve practice.

Criteria for the Use, Processing, and Disposal of Flexible Endoscope Cleaning Brushes

Objectives: To ensure effectiveness in the endoscope channel cleaning process, using functional brushes that are in good condition is necessary. This study sought to identify the criteria for acquiring, using, and disposing of cleaning brushes at endoscopy facilities in Brazil. We further sought to evaluate the conditions of the cleaning brushes in use in the facilities. Methods: This cross-sectional study was conducted between July 2021 and January 2022. Personnel responsible for processing endoscopes were interviewed regarding the use, processing, and disposal of flexible endoscope cleaning brushes. In addition, the brushes used to clean the equipment were inspected. Results: All participants interviewed reported the practice of brushing endoscope channels. Of them, 60% noted the use of disposable brushes, with 40% using reusable brushes. None of the facilities interviewed reported discarding disposable brushes after use. The protocols for disposal of brushes included disposing due to bristle wear (70%), disposal at the end of the day (20%), and an absence of disposal protocols (10%). In addition, 30% of facilities did not clean the bristles before reintroducing them into the channel/lumen, and no facility had an established routine for cleaning brushes between uses. Inspection of brushes revealed that only 20% of facilities had new brushes with no signs of wear or damage. Conclusion: The use of inappropriate brushes/sponges for cleaning endoscope channels and the lack of criteria for the reuse and disposal of brushes increases the risk of cross-contamination, internal damage to channels, and biofilm formation.

Effectiveness of adenosine triphosphate to monitor manual cleaning and disinfection efficacy of flexible endoscopes in Hong Kong

Background and Aim

Adenosine triphosphate (ATP) bioluminescence assay is widely adopted in the West to allow rapid evaluation of endoscopes for bacteriologic/biologic residue, but this practice is rarely adopted in Asia. In this continuous quality improvement program, we evaluated the utility of ATP in bacteriologic surveillance on endoscope reprocessing.

Methods

A total of 456 samples (304 ATP samples and 152 culture samples) of 38 flexible endoscopes were assessed after routine clinical use in a private hospital in Hong Kong. Endoscopes were assessed with an ATP system and bacterial cultures at different time points during the reprocessing.

Results

After pre-cleaning, the ATP values ranged from 228 to 65 163 relative light units (RLU) through all endoscope types. After manual cleaning, ATP values were decreased to 7-81 RLU (median, 19 RLU) for endoscope surface and 3-671 RLU (median, 12 RLU) for channel rinsate. There was a significant reduction in ATP levels between pre-cleaning and after manual cleaning. One of the 38 (2.6%) endoscopes (a duodenoscope) had an ATP value of 671 RLU from channel rinsate, which exceeded the benchmark for cleanliness of >200 RLU, and was sent back for re-cleaning. All endoscopes cultured no bacteria after high-level disinfection (HLD) by automated endoscope reprocessor (AER) and storage up to 24 h. ATP values were <200 RLU for all endoscopes after HLD and storage.

Conclusions

Adenosine triphosphate bioluminescence assay offers a rapid, practical, and cost-effective alternative for detection of endoscope microbial residue as well as a routine monitoring tool for endoscope cleanliness in the clinical setting.