As the Covid-19 pandemic surges across the world, hospitals have had to adjust their practices to minimize patient exposure to the virus. Endoscopic procedures, which introduce reusable endoscopes into the body, are one procedure that many have identified as an area at high risk.
One hospital in Italy recently published research about their experience updating their procedures to reduce the risk of endoscopes passing Covid-19 between patients. Researchers at the University Hospital of Pisa in Italy, where over 13,000 endoscopic procedures are performed annually, studied the presence of Covid-19 on scopes used on Covid-19 positive patients. The goal was to analyze the success of their reprocessing procedures during the pandemic in reducing the risk of spreading Covid-19. Before conducting the study, the hospital updated its endoscopic practices as detailed in this article by Beatrice Casini, Benedetta Tuvo, et al published by the International Journal of Environmental Research and Public Health:
“Regarding the reprocessing of endoscopes, the analysis of the procedure identified critical issues for which improvement actions were taken to reduce the risk of transmitting SARS-CoV-2 infection. The interventions concerned:
- The identification of endoscopes (colonoscopes, gastroscopes, and bronchoscopes), endoscopy columns, and electrosurgical units dedicated for use on COVID-19 patients. Columns were covered by a disposable sheath and at the end of each procedure, the column was subjected to sanitization in accordance with the manufacturer’s instructions. For the disinfection of compatible surfaces, 0.5% sodium hypochlorite, prepared at the moment, was used, while for the monitor, disposable wipes impregnated with 70% isopropyl alcohol were used. Wipes were chosen on the basis of their compliance with the EN 14476:2019 standard. Each column was equipped with a single-patient irrigation bottle and accessory tubing. The transport of the endoscopes in the reprocessing room was organized in dedicated containers and identified with an appropriate color code and risk identification. Care was taken to ensure that the exterior of the containers was not contaminated when loading.
- For the phase involving pre-cleaning of the endoscope, which is conducted at the patient’s bed immediately after the procedure, and for the manual cleaning phase performed in the reprocessing room, the use of enzymatic detergent with disinfectant activity was recommended. The certification of reduction of the viral load according to the EN 14476:2019 standard was required in order to reduce the level of the endoscope contamination, and consequently, to prevent the formation of infectious aerosols, in particular, in the irrigation and brushing of the internal channels phases. Disposable valves were already in use before the COVID-19 emergency. The staff were equipped with the appropriate PPE, which was set up inside the dedicated disposable kit. Due to the limited availability of PPE, face shields were disinfected after use by applying 0.5% sodium hypochlorite, prepared at the moment. In the cleaning phase, the automatic irrigation pump was not recommended in order to avoid contamination since the endoscopy unit did not yet have sterilizable fittings for endoscopes that were potentially contaminated with SARS-CoV-2.
- The leak testing was not recommended in wet conditions due to the risk of aerosol generation. For this reason, dry leak testing was performed in the procedure room while staff were still wearing PPE. Confirmation of a leak test was obtained subsequently within the washer-disinfector cycle.
- Two washer-disinfectors (Soluscope series 4, Soluscope, Aubagne, France) were dedicated to the high-disinfection phase. These machines comply with ISO 15883-1 and ISO 15883-4; therefore, they also guarantee efficacy (high disinfection) against viruses, in particular, on adenovirus type 5, poliovirus type 1, and bovine parvovirus Haden strain. The manufacturer also provided the certification of virucidal activity according to the EN 14476+A1:2015 standard. The intensive high-disinfection cycle was recommended for use. It involves double-washing with enzymatic detergent and high disinfection with peracetic acid at 900 ppm for 3 min at 40 °C. Regarding bronchoscopes, based on their compatibility, hydrogen peroxide gas plasma sterilization (59% H2O2, 55 min, 45 °C) was recommended.
- For the storage phase, endoscope storage drying cabinets (DSC8000-Soluscope, Soluscope Aubagne, France) that conformed to ISO 16442:201519 were identified as suitable because they allowed for better drying of the internal channels of the endoscopes and were equipped with a UV-C system (254 nm), which guarantees the hygienic quality of the storage environment. Specific drawers and connectors were identified for endoscopes that were dedicated to COVID-19 patients.
Finally, to ensure that the endoscope reprocessing procedures were carried out correctly, audits were conducted in the two endoscopy units.
… In this study, the virological analysis carried out on endoscopes where the presence of SARS-CoV-2 was found allowed us to demonstrate that the improvement of the reprocessing process that aimed to reduce the risk of SARS-CoV-2 infections was effective in ensuring the absence of the viral genome and in reducing the risk of SARS-CoV-2 infections after endoscopy on COVID-19 patients.”
As the study notes, hospitals must ensure that staff increase their awareness and adjust their processes to minimize the risk of Covid-19 exposure to their patients. To ensure that your staff is following reprocessing best practices on every scope they disinfect or sterilize, install additional checks and balances into your workflow so that you can document that your staff is following the same process each time. Endoscope tracking software systems such as iRIScope have been introduced in recent years to help hospitals and surgery centers ensure that each of their flexible endoscopes is reprocessed the proper way each time, and documentation of their reprocessing is kept electronically using advanced RFID technology. These systems safeguard the scope disinfection process by employing artificial intelligence to determine if scopes are adequately reprocessed before their next use. With these systems in place, staff and patients can be more confident that their endoscopic procedure won’t result in a life-threatening infection such as Covid-19.