Ever since scandal erupted over superbug outbreaks caused by inadequately cleaned medical scopes, there’s been a pronounced awareness across major healthcare facilities about the need for increased vigilance in processing such equipment. That’s what made it so alarming when a study recently published in the American Journal of Infection Control (AJIC) suggested that those stepped-up efforts might not be making a difference.

To learn more about the research, Surgical Products interviewed Cori Ofstead, MSPH, the study’s lead author.

Will you tell us about your recent research around medical scopes?

The main goal of the study was to determine if endoscopes accumulate damage and debris over time. It’s the first study that’s ever been done to track how scopes change in a relatively short period of time. We examined gastroscopes and colonoscopes three times over a seven-month period and we did that in an institution where they were doing a beautiful job of reprocessing. We knew that before we started this study, and that’s why we selected them, because we wanted to do this study in a place that was doing a good job. They also had really nice scopes — fairly new scopes, not heavily used. And they weren’t being used by medical interns, medical students, or residents who are unfamiliar with scopes and can bang them up. So it was a best case scenario.

We dropped in for unannounced audits nine times during the seven months to make sure that they were still doing everything in accordance to guidelines. What we found at baseline is that there was a fair amount of contamination in the scopes and we could see damage or debris that was concerning in 2 of the 17 scopes.

After the study was started, half of the scopes in the facility began to be reprocessed using more rigorous methods. They were following guidelines that were in place at the time, but we wanted to see if they could get rid of the contamination that we found at baseline if they did things a little more rigorously. So in the intervention group reprocessing techs began to clean all scopes twice and they did testing for cleaning verification. And they also used a stronger disinfectant — peracetic acid — that’s thought to be better at getting rid of biofilm.

By the end — so just seven months after the baseline — all of the scopes had visible evidence of damage or debris. Again, at baseline two of 17 had substantial damage, but at the end, all of them had visible damage and 17 of 20 had substantial enough damage or debris that as researchers we felt that the site should quarantine them and send them out for repair. The site agreed and sent those 17 to the manufacturer for repair, and it was confirmed that there was substantial damage in all of the scopes.

The tests that we did at the end of the study showed that 60 percent of the scopes still had bacteria in them, and over a third had signs that the cleaning didn’t work. The key takeaway here is that scopes that are not heavily used in a place that’s following guidelines still had problems. I think if a scope has sustained damage, it may not be possible to get it all the way clean.

Damaged ends of colonoscopes. Left, scratched, cloudy lens. Right, scratched, scaly lens and dents, brown debris around channel outlets. (Image credit: Ofstead & Associates Inc., American Journal of Infection Control)

And you’re talking about damage sustained through normal usage?

It would be less than normal usage, actually. These scopes were used on average less than once a day. In many institutions, they are using each of their scopes multiple times a day, and in many institutions the devices are put in the hands of medical students, interns, or residents who are unfamiliar with using them, so they might be rougher on the scopes. And some places don’t have certified techs. This ambulatory surgery center, as noted, had scopes that were beautiful, new scopes, in good shape, and all of the providers were highly skilled, experienced proceduralists

What specifically were you seeing with the scopes that made it difficult to get them properly cleaned?

GI scopes are complex — with black insertion tubes, multiple ports, and several channels. Since they’re opaque, you can’t see through them. Thus, the technicians are cleaning in the dark.

These instruments are repeatedly exposed to blood, bodily secretions, tissue, bacterial pathogens, and viruses. They’re exposed to contamination during every case. And it’s imperative to get them cleaned as rapidly as possible after exposure, or that residue — the bodily secretions, blood, and bacteria — can harden on the scope and create something called biofilm. That’s a high risk proposition when you have repeated exposure to contamination and you can’t see whether you get it clean. We think that’s probably a significant root of the reprocessing failures we’re seeing in outbreak situations.

We’re certain the problems we saw with contamination were not attributable to staff making mistakes because the scopes used for upper GI procedures — we call them gastroscopes or EDG scopes — were more highly contaminated than the scopes used for colonoscopies, even though the technicians used exactly the same tools and methods to clean the upper and the lower GI scopes. And this is not something that I would guess. You think of it going through the mouth is not as dirty as going through the other end, right?

We were surprised by that, and these scopes were acquired around the same time, so they were all the same age. They were used for roughly the same amount of procedures and yet half of the time the upper GI scopes didn’t come clean when technicians cleaned them and tested them. In contrast, the colonoscopes almost always came clean the first time.

So there’s something about the scope itself that changes when it’s used for procedures in the upper GI region. It could be that stomach acid and bile could be affecting the surface of the scope and allowing build-up of biofilm and the invasion of microbes. 

Is there something healthcare professionals should be doing right away?

New guidelines have been released by 3 organizations: AAMI, AORN, and SGNA. All of them say the technicians should be doing a very careful visual inspection of the scopes every time they're used. And our study would support that. The guidelines say they should consider using lighted magnification, and I absolutely think they should use a magnifying glass to look at the scopes every time and make sure there’s no damage or debris to that scope. Ideally, they should also be using a tiny camera called a borescope to see inside ports and channels so they can confirm that there’s no damage or debris in there.

I also strongly support the recommendations in all three of those guidelines that say there should be cleaning verification tests. This is because techs cannot see inside of the scope, and cannot tell if they got out all of the debris. They need to be doing something to verify that their manual cleaning efforts worked, and tests can tell if there’s hemoglobin, protein, or ATP still present after cleaning.  If the results are positive, techs can clean it again and run the test again to confirm that the scope is clean.

Is there anything else you want to add?

IAHCSMM has a magazine called Communiqué, and a little pilot study we did this fall was featured in the January issue. It offers a glimpse at the true cost of reprocessing endoscopes, and I think there are a couple key takeaways. In that study, we found that it takes about 75 minutes for a technician to do all of the things needed to reprocess one scope, and it can cost in time and materials anywhere from about $100-$250 dollars or more per scope. In my view, a lot of institutions are not allocating sufficient time nor materials for reprocessing to be done properly, and they’re pressuring those techs to do more with less.

Technicians are moving very rapidly through the steps and they’re turning over scopes to the physician who’s going to do the procedure when they haven’t made sure that that scope really is safe for patient care. In the article we wrote on the cost, it really spells out what the new guidelines are recommending. These steps are going to take more time and resources. If you do visual inspection with a magnifying glass, that takes time. If you do the cleaning verification test, it takes time. And if it’s still dirty, you have to clean it again.

The core of the problem is that facilities aren’t really allocating the personnel or time to do this correctly and they’re also not giving them the training or tools they need. Again, our study that was recently published in AJIC was the best case scenario. That ambulatory surgery center had really nice scopes, really nice equipment for reprocessing, they were following guidelines, and we were there monitoring them and the scopes. That’s really the best case, and it still didn’t work out. There is even greater risk that the scopes being used are damaged or full of contamination in places that aren’t in that best case scenario.