Reprocessing of Flexible Endoscopes

Infection Prevention & Control Policy
Reprocessing of Flexible Endoscopic Instruments
Contents
Purpose ................................................................................................................................................... 1
Policy ....................................................................................................................................................... 1
Scope ....................................................................................................................................................... 1
Definitions ............................................................................................................................................... 2
Roles and responsibilities ....................................................................................................................... 2
Associated documents ............................................................................................................................ 2
1 Personnel ........................................................................................................................................ 2
2 Reprocessing facilities ..................................................................................................................... 3
3 High level disinfection / sterilisation............................................................................................... 3
3.1 General Principles ................................................................................................................... 3
3.2 Cleaning................................................................................................................................... 4
3.3 Sterilisation ............................................................................................................................. 4
3.4 High level disinfection ............................................................................................................. 4
Measurement or evaluation ................................................................................................................... 5
References .............................................................................................................................................. 5
Purpose
 To ensure appropriate and adequate reprocessing of flexible
endoscopes, probes and accessories is undertaken throughout
the CDHB
Policy
Endoscopic instruments that require high-level disinfection or
sterilisation are adequately and safely reprocessed in line with
current best practice standards and guidelines.
Scope
Reprocessing staff in all CDHB areas that are using flexible
endoscopes and probes.
The latest version of this document is available on the CDHB intranet/website only.
Printed copies may not reflect the most recent updates.
Authorised by: EDON Issue Date: July 2016

Page 1 of 5 Be reviewed by: July 2019
In addition to this document, each area must hold their own detailed
departmental cleaning and reprocessing procedures for all types of
instruments used in their department.
Excludes rigid sigmoidoscopy cleaning – refer
Definitions
Endoscopic instruments include:
- Gastroscope
- Colonoscope
- Bronchoscope
- Flexible cystoscope
- Duodenoscope (ERCP)
- Trans oesophageal echocardiography (TOE) probe
- Ultrasonic vaginal probe
- Rectal probe
- ENT scopes (nasoendoscope)
- Oesophageal manometry catheter.
Roles and responsibilities

Delete if not needed. List the role titles and responsibilities, if
relevant to this policy.
Associated documents
This policy is based on the current Australasian GESA/GENCA guidelines,
which is the principal reference document for CDHB endoscopy procedures.
Reprocessing Rigid Sigmoidoscopy Equipment
Departmental Location procedures and policies for specific
instruments and procedures
CDHB IPC Policy, Standard Precautions
1 Personnel
Personnel performing reprocessing of endoscopic instruments shall
demonstrate competency in the care and reprocessing of instruments
and related equipment. Where possible, training in the correct
handling and / or use of equipment and products shall be provided by
equipment/product representatives.

Competency shall be reassessed annually

Personnel shall also demonstrate competency in infection prevention
and control and safe use of chemicals.
Appropriate personal protective equipment must be worn.
2 Reprocessing facilities
Work areas for reprocessing endoscopic instruments shall be planned
and organised carefully to ensure staff safety and to protect
reprocessed instruments from re- contamination or damage. Work flow
should be from dirty to clean with segregation of areas where possible.
Where required the work area should incorporate the following core
facility components:
 A designated ‘dirty’ sink for cleaning instruments
 A ‘dirty’ bench adjacent to this sink for holding dismantled
components awaiting cleaning and cleaned equipment awaiting
high-level disinfection.
 An area for high-level disinfection of instruments. The size of this
area will depend on the method of disinfection. Automated
reprocessors will require plumbing.
 For areas that require manual rinsing a sink designated for
rinsing clean instruments is required
 A ‘clean’ area for reassembly of the disinfected instrument prior
to storage and reuse.
Ventilation of the reprocessing area is important to prevent inhalation of
chemical fumes. Ventilation requirements will depend on the chemical
products in use. Occupational Health & Safety will advise.
3 High level disinfection / sterilisation
3.1 General Principles

Endoscopic instruments are considered semi-critical devices according
to Spaulding’s classification as described below:
‘Items that come into contact with mucous membrane or non-intact skin
should be single use or sterilised after each use. Where this is not
possible, high level disinfection is the minimum level of reprocessing
acceptable.’
The IP&C Service must be consulted when considering the choice
of sterilisation or high level disinfection methods

Personnel shall routinely inspect instruments and all related equipment and
supplies for integrity, function, and cleanliness. Damaged or soiled
instruments or accessories shall not be used.
3.2 Cleaning
Cleaning is the most important step in reprocessing of instruments and
is an essential pre-requisite to disinfection or sterilisation
All instruments shall be pre-cleaned according to the manufacturer’s
guidelines immediately following the procedure. If immediate cleaning
is not possible, the instrument must be wiped to remove excess soiling
and then soaked until reprocessing is undertaken.
In some cases leak testing must be undertaken prior to soaking.
Follow the manufacturer’s instruction for the preparation and use of an
enzymatic detergent if used.
Detergent must be rinsed off the instrument prior to further
reprocessing
3.3 Sterilisation
Reprocessing for each instrument shall be performed according to the
manufacturer’s instructions specific to that instrument - either
sterilisation or high-level disinfection.
When a steriliser is used, manufacturer’s instructions for use shall be
followed. All sterilisation processes are undertaken in a dedicated
sterilisation department or area.
3.4 High level disinfection

All disinfectant solutions used for endoscopic instruments and
compatible accessories must be approved by the IP&C Service as a
suitable high-level disinfectant. Manufacturer instructions shall be
followed in the preparation, testing and use of the disinfectant solution.
Manufacturer guidelines for exposure time and temperature shall be
followed. Each instrument and it components shall be completely
immersed in the disinfectant solution and all channels must be
disinfected during reprocessing.
Following high-level disinfection, all instruments and accessories shall
be rinsed and dried in accordance with manufacturer instructions.

When an automated processor is used, manufacturer’s directions for

processing shall be followed.
Disinfected and dried instruments shall be properly stored in a vertical
position away from the reprocessing area in a location that will provide
protection from contamination.
Reusable endoscopic accessories that disrupt or enter the mucosal
barrier will be mechanically cleaned and sterilized after each patient
use.
If automated processors and/or sterilizers are used, maintenance and
repair shall be performed according to manufacturer instructions and
shall be documented.
Measurement or evaluation
Compliance with reprocessing procedures is undertaken annually by
the IP&C Service for all departments undertaking reprocessing of
endoscopic instruments
References
GENCA, & GESA (2010). Infection Control in Endoscopy (3rd ed.)
Victoria, Australia: Gastroenterological Society of Australia.
NZS 8134.3:2008 Health & Disability Services (Infection Prevention
and Control) Standards.
AS/NZS 4187:2014, Reprocessing of reusable medical devices in
health service organisations.
Policy Owner Infection Prevention & Control Service

Policy Authoriser Executive Director of Nursing
Date of Authorisation 22nd July 2016


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Infection Prevention & Control Policy

Reprocessing of Flexible Endoscopic Instruments

Reprocessing of Flexible Endoscopic Instruments

Authorised by: EDON Issue Date: July 2016

Reprocessing of Flexible Endoscopic Instruments

Roles and responsibilities

Authorised by: EDON Issue Date: July 2016

Reprocessing of Flexible Endoscopic Instruments

Competency shall be reassessed annually

3 High level disinfection / sterilisation

3.1 General Principles

Authorised by: EDON Issue Date: July 2016

Reprocessing of Flexible Endoscopic Instruments

3.4 High level disinfection

Authorised by: EDON Issue Date: July 2016

Reprocessing of Flexible Endoscopic Instruments

When an automated processor is used, manufacturer’s directions for

Policy Owner Infection Prevention & Control Service

Authorised by: EDON Issue Date: July 2016

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