An article on cleaning and disinfection / sterilization of endoscopic instruments

Endoscopic instruments continue to evolve .

What makes these instruments different -

• Cost

• Complexity

• Limited stock

• Specificity

• Long time lag for repairs and procurement to replace .

Therefore , we need to be certainly extra-careful while handling and processing this particular group of instruments .

Once stakeholders zero down on its purchase , before taking a final call they should involve CSSD head to evaluate -

1. Feasilibility for dismantling, cleaning , Sterilization / disinfectantion.

2. Container / rack to protect these instruments during handling and transport .

3. Quantity needed considering proposed number of cases and turn around time .

4. Availabilty of trained Manpower or need for training .

5 .If possible , demo set / device should be actually brought for trial and all the team members ( practicing clinician , assisting nurses , technician and processing technologists ) should be involved in decision making sothat clarification on challenges can be obtained.

6. Atleast video of instruments to be ordered can be shared that demonstrates working , processing and maintenance of the device.

7. Company should be asked to assist all the stakeholders for handholding till they get well versed with entire cycle of its application.

8. All the IFU ( instructions for use )and diagrammatic illustration should be included in operating manual and training of all concerned should be documented ,with post training evaluation that is authorised by head of the department and trainer .

9. Exhaustive check lists should be a part of routine activities including discription of all the accessories , preferably with images for easier identification .Once sets are prepared , instruments and accessories to be packed separately is decided ,then it's equally important to mention about racks, containers and size with type of packaging.

Next step will be to conduct a meeting with user department and CSSD working team to decide about pre- cleaning , transport ,checking , communication ( about non-routine hindrances ) ,processing( specifying cycle parameters in terms of temperature,pressure / number of vacuum pulses ,hold time and dry time ) and return sothat all the team members are clear about entire cycle of reprocessing right from opening of sterile pack till receiving back processed pack .Mainly every one should know their respective role , responsibility and accountability .This is called working system .

Now ,let's look at individual steps -

Pre- cleaning - As soon as instruments are taken out from body cavity it is very important to either wipe it using mop soaked in enzymatic detergent or keep it soaked in an appropriate container provided for this purpose ,aim being not to allow blood and body fluids dry on the device.

This is very critical as it takes care of almost entire organic soil and majority of bio- burden .At the same time it makes subsequent treatment more effective .Lumens need to be immediately flushed copiously.Attachments connected to operating system need to be rinsed following manufacturers guidelines before even disconnecting from the equipment that helps in providing needed agitation to dislodge adhered muck .

Transport - This too is a very important step as here safety of delicate instruments is a major concern .Thus replacing tips , using racks / stands , containers and shifting trolleys need to be specified .

Handing over to CSSD -

Here first step is checking by a technologist who is trained thus well versed with various parts of assembly , use of instruments ( to figure out damage or dis- function ) and set contents sothat in case of discrepancy , accountability can be ascertained.

Then comes dismantling , manual / automated ( if recommended ) cleaning , flushing / thorough rinsing and drying .

Set is then handed over carefully to assembling person along with important communication ,if any .

Here again all the contents are thoroughly checked for cleanliness , integrity ,complition of assembly ,protecting tips , accessories etc .as per check list and set is packed in appropriate container with specified wrappers depending on choice of sterization process .

After Sterilization , set is carefully unloaded , stored in sterile store at a designated place and handed over to user department following laid down safety protocol .

Material that needs disinfection is ideally processed at the endoscopy department or Operating Room itself to restrict number of people involved in the process .

Important instructions to be followed for disinfection are -

Choice of disinfectant - recommended by manufacturer .

In house validation of that process in terms of active concentration ,contact time , removal of residues ,drying and operator safety ,along with documented instructions about post - case decontamination, pre-case disinfection and post - disinfection aseptic handling .

Check list and operator's signature after carrying out the process is very important from tracebility point of view .

Here supervisors role is very important as unlike Sterilization ,quality control and Assuarance are system and operator dependant making it error prone .

Wherever available , disinfectant concentration check strips should be used and documented .

Records of all the results should be regularly checked by Supervisor before releasing the sterile / disinfected material for use on patient .

With adequate training , knowledge of application , standard operating protocols and quality control program CSSD plays a pivotal role in patient safety.

With best regards .

Gauri Bhatia,

Consultant and trainer - Infection and Prevention*