Appendix F: Infection Prevention and Control Guideline for Flexible Gastrointestinal Endoscopy and Flexible Bronchoscopy – Sample audit tool for reprocessing of endoscopy equipment/devices

APPENDIX F - Sample Audit Tool for Reprocessing of Endoscopy Equipment/Devices

Adapted from Kingston Hospitals

  Recommendation Specific Procedure Yes/No/NA MRP Comment/Strategy for Improvement
1. There is compliance with endoscope manufacturer's recommendations for cleaning.
  1. Endoscope is wiped and flushed immediately following procedure.
  2. Removal of debris collected in scope (brushing).
  3. Removal of debris collected on the scope (surface cleaning).
  4. Perform a Leak test.
  5. Visually inspect the scope to verify working properly.
2. Verify that endoscope can be reprocessed in site's automated endoscope reprocessor (AER).
  1. Documentation from endoscope's manufacturer confirming compatibility of each scope with AER.
  2. Documentation from AER manufacturer confirming testing of individual scope in system.
  3. Specific steps before reprocessing endoscope's in AER.
3. Compare reprocessing instructions provided by AER manufacturer and scope manufacturer and resolve conflicts.
  1. Conflicts identified and resolved.
  2. Compliance with manufacturer's recommendations for hospital approved chemical germicide.
4. Adhere to endoscope manufacturer's instructions for manual reprocessing in the absence of specific technical information on AER reprocessing.
  1. Manual procedures in place for endoscopes not compatible with AER.
  2. Compliance with manufacturer's recommendations for hospital approved chemical germicide.
5. Reprocessing protocol incorporates a final drying step.
  1. All channels of reprocessed endoscopes are flushed with alcohol followed by purging with air.
6. Staff adheres to facility's procedures for preparing endoscope for patient.
  1. Confirm AER's processes are applicable to specific endoscope's models.
  2. Ensure endoscope-specific reprocessing instructions from AER mfg are correctly implemented.
  3. Written, device-specific instructions for every endoscope's model available to reprocessing staff.
  4. Written instructions for reprocessing system are available to reprocessing staff.
7. Comprehensive and intensive training is provided to all staff assigned to reprocessing endoscopes.
  1. New reprocessing staff receives thorough orientation with all procedures.
  2. Competency is maintained by periodic (annual) hands on training with every endoscope model and AER used in the facility.
  3. Competency is documented following supervision of skills and expertise with all procedures.
  4. Frequent reminders and strict warnings are provided to reprocessing staff regarding adherence to written procedures.
  5. Additional training with documented competency for new endoscope models or AER.
8. A comprehensive quality control program is in place.
  1. Periodic visual inspections (monthly) of the cleaning and disinfecting procedures.
  2. A scheduled endoscope's preventive maintenance program is in place and documented.
  3. Preventive maintenance program for AER is in place and documented.
  4. Preventive maintenance program for all reprocessing system filters is in place and documented.
  5. AER process monitors are utilized and logged.
  6. Chemical germicide effectiveness level is monitored and recorded in a logbook.
  7. There are records documenting the use of each AER which include the operator identification, patient’s chart record number, physician code, endoscope serial # and the type of procedure.
  8. There are records documenting the serial # of scopes leaving the Endoscope reprocessing area (e.g., repairs, loaners, O.R., etc.)
  9. There is a surveillance system that detects clusters of infections/pseudoinfections associated with endoscopic procedures.
9. Staff adheres to Routine Practices.
  1. Ensure correct hand hygiene technique is performed in appropriate situations.
  2. There is compliance with procedures for wearing clean, non-sterile gloves.
  3. PPE (masks, eye protection, gown, plastic apron) is worn during procedures and patient care activities that are likely to generate splashes or sprays.
  4. Appropriate PPE is worn during scope cleaning and reprocessing.
  5. Heavily soiled linen is placed into plastic bag prior to depositing in linen hamper.
  6. Procedures are in place to prevent sharps injury.
  7. Staff is knowledgeable regarding protocol for follow-up for blood/body fluid exposure.
10. Endoscope reprocessing policies and physical space are in compliance with workplace regulations and standards.
  1. All procedures are in compliance with federal/provincial Occupational Health and Safety regulations/legislation.
  2. The reprocessing physical space is in compliance with the Canadian Standards association standards and federal/provincial Occupational Health and Safety regulations/legislation.

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