Problem statement: Scope technicians and clinical staff members are not adhering to the standards of endoscope reprocessing within the organization’s policy, instruction for use (IFU) equipment manuals, and current national standards and guidelines. There are variations in practices across multiple categories that influence endoscope reprocessing including people, processes, equipment, materials, environment, and management. The organization identified a need to develop a well-defined policy for managing high-level disinfection (HLD) specific to endoscope reprocessing.
Interventions: With the organization’s commitment to achieving zero patient harm, the nursing education department partnered with key stakeholders such as infection preventionist, sterile processing departments (SPD), scope technicians, environmental health and safety specialists, and regulatory departments to create standardized processes for endoscope reprocessing. After completion of a thorough root cause analysis, the following interventions were implemented to address system issues:
1) revision of the organization’s policy to establish a clear, step-by-step HLD process, standardizing HLD logs and incorporating the new 2022 AAMI National Standards; 2) development and implementation of the organization’s training for managers and staff, including an e-learning module, manager webinar, and HLD-specific endoscope competency; 3) creation of a new audit tool in an electronic reporting system, continuously monitoring department’s adherence, maintenance and identifying gaps and trends across the system; 4) development of the endoscope reprocessing committee, including key super users from each department where endoscope reprocessing occurs to disseminate information and assess adherence to the policy and IFUs; 5) development of a comprehensive multidisciplinary rounding plan by regulatory, infection prevention, nurse education, and managers; and standardization of equipment, purchasing, and expansion of HLD into new locations.
Outcome: Outcomes were evaluated over the course of 2022 and can be presented in the following categories:
People: 100% compliance with training through e-learning modules and competencies. Maintained greater than 90% endoscope reprocessing committee participation from May 2022-October 2022.
Process: At baseline (2021), only 20% of the departments completed the paper spot-check audits. After implementing the electronic audit tool in August 2022, compliance for department audits increased to 60%.
Equipment: Standardized endoscope cabinets and process for maintenance.
Environment: Standardized lighting, magnification, temperature and humidity monitoring, and HLD room cleaning.
Significance/implications for practice: Comprehensive multidisciplinary actions improve adherence to endoscope reprocessing standards. Utilizing multiple modalities to teach the staff the necessary skills increased staff repetition to successfully perform endoscope reprocessing. Additionally, physical rounding in departments and monthly committee meetings increase staff engagement and compliance to continually sustain zero patient harm.
1) Association of Perioperative Registered Nurses (AORN). (2019). Flexible endoscopes. In Guidelines for perioperative practice (pp. 199–388). Denver, CO: AORN, Inc.
2) Association for the Advancement of Medical Instrumentation. (2017). ANSI/AAMI ST79: Comprehensive guide to sterilization and sterility assurance in healthcare facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation.
3) Association for the Advancement of Medical Instrumentation. (2022). ANSI/AAMI ST91:2021 Flexible and semi-rigid endoscope reprocessing in healthcare facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation.