Cleaning endoscopes; advance medication preparation; reusing irrigation setups; procedure masks; fire safety; reusing blades - Clinical Issues

AORN Journal,  Nov, 2003  by Dorothy Fogg

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QUESTION: I work in a hospital-based, but separate, ambulatory surgery unit. We recently remodeled our facility, and in that process, the soiled utility/decontamination area was converted to an office. We now have no place to clean the endoscopes used by our large gastrointestinal endoscopy service. We use the peracetic acid system for processing, but the endoscopes first must be cleaned and decontaminated. The processing system is in the substerile area between the ORs, so we rinse the endoscopes and flush the channels in that area before placing them in the processor. The only running water in the area is at the handwashing sink. Sending our surgical instruments to the central processing department is not an option because the turnaround time is too long and several cases are scheduled in sequence on any given day. Is it acceptable practice to dean the endoscopes in the substerile area if they are placed immediately in the processing system?

ANSWER: It is not acceptable practice to clean the endoscopes in the substerile area. Neither is it acceptable to simply rinse them off and flush the channels before placing them in the processor. Endoscopes, like other supplies, should be transported from the clean area where they are processed, through the procedure room, to the peripheral corridor and decontamination area. Soiled items should not re-enter clean areas, such as the substerile room. They should be contained in closed or covered containers when transported to the designated decontamination area. The decontamination area should be separated from personnel and patient traffic areas. (1,2) Handwashing sinks are not designed to receive or transport sewage. By using the handwashing sink for cleaning the endoscopes, you are contaminating the substerile area.

Gastrointestinal endoscopes, by virtue of the body cavities in which they are used, acquire high levels of microbial contamination during each used. (3) Upon arrival in the designated decontamination area, endoscopes and their accessories should be disassembled and cleaned manually, using mechanical friction when possible. Removing gross soil from narrow internal channels and lumens may be difficult. Manufacturers' instructions may vary according to the specific device, and the instructions for cleaning should be followed carefully. AORN's "Recommended practices for cleaning and processing endoscopes and endoscopic accessories' provide the following sample protocol for cleaning endoscopes before placing them in the processor. (4)

* Wash the insertion end of the endoscope with an enzymatic detergent solution using a soft cloth or sponge.

* Remove all detachable parts leg, hoods, valves, water bottle) and soak in the enzymatic detergent solution.

* Open all ports during the cleaning process.

* Irrigate internal suction/biopsy channels with copious amounts of enzymatic detergent solution and water.

* Brush accessible channels to remove particulate matter.

* Clear the air-water channel with forced air.

* Gently brush or wipe the tip of the endoscope to remove any debris or tissue lodged around the air-water outlet.

* Clean detached parts in the enzymatic solution using a brush for irregular surfaces.

* Thoroughly rinse the endoscope and all its parts.

* Thoroughly dry the endoscope, channels, and removable parts.

* Discard the enzymatic detergent solution after use. The solution has no antimicrobial properties and may allow microbial growth.

As is evident from this sample protocol for endoscope cleaning, it is impossible to adequately clean endoscopes in the substerile area using only a handwashing sink. The endoscopes should be cleaned in a decontamination area specifically designed for that purpose. If there is no decontamination area in your facility, you will need to purchase enough endoscopes to accommodate the time necessary to send them to the central processing area, have them cleaned and decontaminated, and returned to you for final sterilization.

QUESTION: An ophthalmologist at our facility performs several procedures in sequence during his assigned block time each week. He has requested that we prepare all the medications to be used for his patients on a given day before the first case of the day. The prepared medications are to remain with the circulating nurse until they are placed on the sterile field for each patient in turn. The surgeon believes this will save time and allow more cases to be scheduled within the block of time. On some days, the types of medications and dosages are the same for every patient, but often there are differences. Sometimes the medications have to be changed after the procedure begins. The circulating nurses are uncomfortable with this scenario and believe it jeopardizes patient safety. What is AORN's opinion?

ANSWER: AORN is opposed to the practice you describe. Having multiple medications prepared for patients who are not yet in the OR provides opportunity for error throughout the day. An incorrect medication could be selected and presented to the sterile field at any time. Syringes may be jostled around and out of sequence without the circulating nurse realizing this has happened. Presumably the syringes are labeled, but a brief glance at the label may result in the wrong medication being presented to the field. If the circulating nurse is relieved at any point during the day's schedule, the relief circulating nurse would be placed in the position of delivering medications to the field that he or she had not prepared personally. This conflicts with basic standards of nursing practice and is contrary to safe medication-handling practices.