INFECTION PREVENTION

AND CONTROL GUIDELINE

Flexible Gastrointestinal
for
Endoscopy and Flexible Bronchoscopy
To promote and protect the health of Canadians through leadership, partnership,
innovation and action in public health.
— Public Health Agency of Canada

Infection Prevention and Control Guideline for Flexible Gastrointestinal Endoscopy and Flexible Bronchoscopy
is available on Internet at the following address: http://www.phac-aspc.gc.ca

Également disponible en français sous le titre :

Lignes directrices pour la prévention et le contrôle des infections transmises par les appareils souples
d'endoscopie digestive et de bronchoscopie.

This publication can be made available in alternative formats upon request.

© Her Majesty the Queen in Right of Canada, 2010

Cat.: HP40-55/2010E-PDF ISBN: 978-1-100-17223-1
 Table of Contents
Introductory Statement.................................................................................................................... 5
Executive Summary ........................................................................................................................ 8
PART I. PURPOSE .................................................................................................................... 11
PART II. TRANSMISSION OF INFECTION BY FLEXIBLE ENDOSCOPY ....................... 12
1. Background ........................................................................................................................... 12
1.1. Spaulding Classification for Medical Devices.............................................................. 12
2. Overview............................................................................................................................... 12
3. Microbial Sources ................................................................................................................. 13
3.1. Endogenous................................................................................................................... 13
3.2. Exogenous..................................................................................................................... 14
4. Specific Microorganisms Transmitted or Shown to Contaminate Flexible Endoscopes...... 16
5. Occupational Infection Related to Endoscopy...................................................................... 19
6. Classic and Variant Creutzfeldt-Jakob Disease .................................................................... 20
7. Factors That Contribute to Survival of Microorganisms in Reprocessed Flexible Endoscopes
............................................................................................................................................... 21
7.1. Wet Storage................................................................................................................... 21
7.2. Biofilm Formation and Organic Debris ........................................................................ 22
7.3. Equipment Design Flaws .............................................................................................. 22
8. Errors in Reprocessing.......................................................................................................... 22
PART III. FLEXIBLE ENDOSCOPES: STRUCTURE and FUNCTION ................................ 24
PART IV. ISSUES RELATED TO REPROCESSING FLEXIBLE ENDOSCOPES ............... 29
1. Reprocessing of Flexible Endoscopes and Accessories........................................................ 29
1.1. Pre-Cleaning ................................................................................................................. 35
1.2. Leak Test....................................................................................................................... 35
1.3. Manual Cleaning and Rinsing....................................................................................... 36
1.4. Disinfection and Sterilization ....................................................................................... 37
1.4.1. Selection of a High Level Disinfectant Product ....................................................... 38
1.4.2. Liquid Chemical Agents ........................................................................................... 38
1.4.3. Low Temperature Gas and Gas Plasma Sterilization ............................................... 39
1.4.4. Automated Endoscope Reprocessors (AERs)........................................................... 44
1.4.5. Reprocessing Endoscopic Accessories ..................................................................... 45
1.4.6. Valves and Water Bottles.......................................................................................... 47
2. Sheathed Endoscopes............................................................................................................ 47
3. Storage of Flexible Endoscopes............................................................................................ 47
4. Quality Management............................................................................................................. 48
4.1. Staff Training ................................................................................................................ 49
4.2. Preventative Maintenance and Repair .......................................................................... 50
4.3. Monitoring Microbial Bioburden in Flexible Endoscope Channels ............................. 50
5. Healthcare Worker Protection During Endoscopy/Bronchoscopy and During Equipment
Reprocessing ......................................................................................................................... 51
5.1. Hazards During Endoscopy .......................................................................................... 51
5.2. Hazards During Reprocessing....................................................................................... 51
5.3. Infection Prevention and Control Practices and Precautions........................................ 52
5.4. Occupational Health and Safety Considerations........................................................... 52
5.5. Environmental Controls ................................................................................................ 53
6. Endoscopy Unit Design ........................................................................................................ 53
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7. Surveillance and Outbreak Investigation and Management ................................................. 54
8. Investigation of a Reprocessing Problem ............................................................................. 54
PART V. RECOMMENDATIONS FOR REPROCESSING FLEXIBLE ENDOSCOPES...... 57
1. Administrative Recommendations........................................................................................ 57
1.1. Policies and Procedures ................................................................................................ 57
2. Recommendations for Endoscopy and Endoscopy Decontamination Equipment................ 58
3. Recommendations for Reprocessing Endoscopes and Accessories...................................... 60
3.1. Preparing the Endoscope for Cleaning ......................................................................... 60
3.2. Leak Testing.................................................................................................................. 61
3.3. Manual Mechanical Cleaning in the Reprocessing Area.............................................. 61
3.4. Sterilization and High Level Disinfection .................................................................... 62
3.5. Recommendations for Accessories ............................................................................... 64
3.6. Storage and Transport ................................................................................................... 65
4. Recommendations for Endoscopy Unit Design.................................................................... 65
5. Recommendations for Quality Management ........................................................................ 66
5.1. Personnel Education and Training ................................................................................ 66
5.2. Worker Health and Safety............................................................................................. 67
5.3. Reprocessing Program .................................................................................................. 68
6. Recommendations for Outbreak Investigation and Management......................................... 69
7. Recommendations for Classic and Variant Creutzfeldt-Jakob Disease (CJD and vCJD))... 70
APPENDIX A – PHAC IP&C Guideline Development Process ................................................. 72
APPENDIX B – Glossary of Terms ............................................................................................. 74
APPENDIX C – Spaulding Classification System ....................................................................... 77
APPENDIX D – Bioburden Test Method..................................................................................... 78
APPENDIX E – Sample Audit Checklist for Reprocessing of Medical Equipment/Devices...... 81
APPENDIX F – Sample Audit Tool for Reprocessing of Endoscopy Equipment/Devices ......... 84
APPENDIX G – Verification of Training Stages for Endoscope Reprocessing .......................... 87
APPENDIX H – Guideline for Outbreak Investigation Related to Endoscopic Procedures........ 90
APPENDIX I – PHAC Guideline Rating System......................................................................... 91

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 Introductory Statement

The Public Health Agency of Canada (PHAC) develops national infection prevention and control
guidelines to provide evidence-based recommendations to complement provincial/territorial
governments’ efforts in monitoring, preventing, and controlling healthcare-associated infections.
National guidelines support infection control professionals, healthcare organizations and
healthcare providers in the development, implementation and evaluation of infection prevention
and control policies, procedures and programs to improve the quality and safety of health care
and patient outcomes.
The purpose of the PHAC Guideline Infection Prevention and Control Guideline for Flexible
Gastrointestinal Endoscopy and Flexible Bronchoscopy is to provide a framework within which
those responsible for endoscopes in all settings, where endoscopy is performed, may develop
policies and procedures to ensure that the critical elements and methods of cleaning, disinfection,
and/or sterilization of these devices between patient uses are consistent with national guidelines.

Guidelines, by definition, include principles and recommendations, and should not be regarded
as rigid standards. This guideline, whenever possible, has been based on research findings. In
some areas, where there is insufficient published research, a consensus of experts in the field has
been used to provide recommendations specific to practice.

The information in this guideline was current at the time of publication. Scientific knowledge
and medical technology are constantly evolving. Research and revisions to keep pace with
advances in the field are necessary.

Target Users

This guideline is intended to assist infection prevention and control professionals and all other
healthcare providers responsible for using and reprocessing flexible gastrointestinal endoscopes
and flexible bronchoscopes in all settings in which endoscopy is performed, whether in hospitals,
clinics, physician offices, or stand-alone endoscopy centres.

Guideline Working Group

The Public Health Agency of Canada’s Infection Prevention and Control Program developed this
guideline with expert advice from a working group. The Guideline Working Group was
comprised of members representing clinical microbiologists, endoscopy nurses,
gastroenterologists, hospital epidemiologists, infectious disease specialists, infection prevention
and control professionals, biomedical technicians and the medical instrument reprocessing
sector. The multidisciplinary Guideline Working Group reflected a balanced representation of
the regions of Canada.

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The following individuals formed the Guideline Working Group:
ƒ Dr. Jonathan R. Love, Co-chair, Clinical Associate Professor of Medicine,
Division of Gastroenterology, University of Calgary, Calgary, Alberta
ƒ Dr. Anne Matlow, Co-chair, Director, Infection Prevention & Control Program
The Hospital for Sick Children, Toronto, Ontario
ƒ Dr. Michelle Alfa, Assistant Director, Microbiology Lab, St Boniface General Hospital,
Winnipeg, Manitoba
ƒ Sandra Boivin, Agente de planification, programmation et recherche, Direction de la Santé
publique des Laurentides, St-Jérôme, Québec
ƒ Cindy E. Hamilton, Writer, Hamilton, Ontario
ƒ Linda Jakeman, Manager, Sterile Processing, Capital District Health Authority, Dartmouth
General Hospital, Dartmouth, Nova Scotia
ƒ Lorie McGeough, President, Canadian Society of Gastroenterology Nurses & Associates,
Regina, Saskatchewan
ƒ Cathy Oxley, Writer, Ottawa, Ontario
ƒ Dr. Alice Wong, Infection Control Officer, Saskatoon Health Region, Department of
Medicine, Royal University Hospital, Saskatoon, Saskatchewan
ƒ Curtis Yano, Biomedical Technician, Royal Alexandra Hospital, Edmonton, Alberta

The Public Health Agency of Canada’s team for this guideline included:
ƒ Luna Bengio, Director, Blood Safety Surveillance and Health Care Associated Infections,
Centre for Communicable Diseases and Infection Control
ƒ Kathleen Dunn, Manager, Infection Prevention and Control Program
ƒ Christine Weir, Nurse Epidemiologist and Acting Manager, Infection Prevention and Control
Program
ƒ Frederic Bergeron, Nurse Consultant
ƒ Rolande D’Amour, Nurse Consultant
ƒ Judy Foley, Literature Database Officer
ƒ Jennifer Kruse, Nurse Consultant
ƒ Louise Marasco, Editing and Quality Control Officer
ƒ Laurie O’Neil, Nurse Consultant
ƒ Shirley Paton, Senior Technical Advisor
ƒ Carole Scott, Publishing Officer/Literature Database

In collaboration with Health Canada:

ƒ Melanie Weger, Reference Librarian

Guideline Issuance and Review

This guideline was issued in 2011 and will be reviewed in 2013, or sooner if new evidence
becomes available. Any amendments to this guideline in the interim period will be noted on the
PHAC website. Comments are invited to assist the review process.

Please refer to Appendix A for a summary of the PHAC Infection Prevention and Control
Guideline Development Process.

6
This document is part of the PHAC series of Infection Prevention and Control Guidelines and is
intended to be used with the other Infection Prevention and Control Guidelines. The series is
available at: www.phac-aspc.gc.ca/nois-sinp/guide/pubs-eng.php

For information regarding the Infection Prevention and Control Guidelines series, please contact:

Centre for Communicable Diseases and Infection Control

Blood Safety Surveillance and Health Care Associated Infections Division
Infection Prevention and Control Program
Tel: 1-800-622-6232 (1-800-O’CANADA)
Web-link: www.phac-aspc.gc.ca/contac-eng.php

7
 Infection Prevention and Control Guideline for Flexible
Gastrointestinal Endoscopy and Flexible Bronchoscopy

Executive Summary

This document, Infection Prevention and Control Guideline for Flexible Gastrointestinal
Endoscopy and Flexible Bronchoscopy, has been prepared by the Public Health Agency of
Canada’s Blood Safety Surveillance and Health Care Associated Infections Division of the
Centre for Communicable Diseases and Infection Control. It is intended to assist infection
prevention and control personnel and all other healthcare providers responsible for both using
and reprocessing flexible gastrointestinal endoscopes and flexible bronchoscopes in all settings
in which endoscopy is performed, whether in hospital clinics, physician offices, or stand-alone
endoscopy centres. The recommendations provide a framework within which those responsible
for endoscopy in any setting may develop policies and procedures to address their needs, and to
ensure that the critical elements and methods of cleaning, disinfection, and/or sterilization of
these devices between patient uses are consistent with national guidelines.

Numerous types of flexible endoscopes are available (e.g., gastrointestinal, bronchoscopic,

urological, laparoscopic surgical, etc). This Guideline will focus solely on flexible
gastrointestinal and bronchoscopic endoscopes and their respective accessories. Instruments
such as transesophageal or rectal ultrasounds, cystoscopes, laparoscopes and others are examples
of instruments that will not be addressed. For purposes of this document, ‘patient’ includes
patient, client or resident. The Public Health Agency of Canada guidelines provide evidence-
based recommendations. Where scientific evidence is lacking, the consensus of experts is used to
formulate a recommendation. As new information becomes available, the recommendations in
this document will be reviewed and updated.
Parts I and II describe the purpose of this Guideline and provide background information on the
epidemiology, etiology, and pathogenesis of infections associated with flexible endoscopy, in
order to bring an understanding of how disease can be transmitted by these instruments. Briefly,
endoscopy-related infections can result from 1) the patient’s own (endogenous) microbial flora,
or 2) microorganisms acquired a) exogenously from a contaminated endoscope, and/ or b)
transmitted between the patient and the healthcare provider. Each category is reviewed in the
document, with a focus on the sources and modes of acquisition of exogenously acquired
microorganisms and specific microorganisms and problems (e.g., breaches in disinfection or
sterilization processes) associated with transmission of disease attributed to a contaminated
endoscope.
Part II further elaborates on the factors that contribute to the survival of microorganisms in
reprocessed endoscopes. Common errors in reprocessing are highlighted. The Guideline
emphasizes the steps required to address these factors, and points out the critical need for
appropriate training and ongoing competency assessment for staff in the reprocessing area.
Part III describes the structure and function of the endoscope with corresponding illustrations.

8
Part IV provides detailed instructions on the critical steps required for reprocessing endoscopes
and describes the barriers to adequate reprocessing that may lead to transmission of infection.
Endoscope reprocessing is a three-stage process that includes: 1) cleaning the endoscope and its
detachable parts using a detergent solution and brushes; 2) high level disinfection or sterilization
of the endoscope using a product, most often a liquid chemical agent, approved for use in
Canada, followed by thorough water rinsing to remove residual product from the instrument; and
3) post-processing, which includes proper handling and storage of the endoscope. In Part IV,
major attention is given to the safe use of automated endoscope reprocessors, the proper
reprocessing of endoscopic accessories, and the storage requirements for flexible endoscopes.
Part IV also includes important sections on quality management, healthcare worker protection,
health and safety considerations related to endoscopy and equipment reprocessing, appropriate
endoscopy unit design, outbreak investigation and management, and finally, investigation and
action required if a reprocessing problem is identified. These sections of the document are
intended to provide the user with the knowledge and tools to ensure that the endoscopy working
environment is safe for patients and staff, that staff are appropriately trained and competency
assessment is ongoing, and that potential outbreaks of infection or reprocessing problems are
identified and managed effectively and in a timely fashion.
Part V sets forth evidence-based recommendations for reprocessing flexible gastrointestinal
endoscopes and flexible bronchoscopes, including recommendations for administrative policies
and procedures, cleaning, leak testing, sterilization and high level disinfection, and storage and
transportation. The recommendations in this Guideline take into account guidelines and
recommendations published by other national and international societies and organizations(1-
10)
.The recommendations elaborate on quality management, specifically, education and training
requirements, worker health and safety considerations, and the quality assurance elements of a
reprocessing program. Other recommendations deal with classic and variant Creutzfeldt-Jakob
Disease, outbreak investigation and management, and endoscopy unit design.
Appendix A. The “PHAC Infection Prevention and Control Guideline Development Process”
provides a summary of the guideline development process.
Appendix B. The “Glossary of Terms” provides definitions of terms used throughout these
guidelines.
Appendix C. The “Spaulding Classification System” is used for making decisions about
whether to use sterilization or high level disinfection on endoscopic equipment between each
patient use.
Appendix D. The “Bioburden Test Method” describes a procedure for microbiologic testing of
endoscopes that may be undertaken as part of an outbreak investigation.
Appendix E and F. These two sections, “Sample Audit Checklist/Tools for Reprocessing of
Endoscopy Equipment/Devices”, provide examples of quality assurance tools to audit
reprocessing practices to verify that equipment/devices are being reprocessed according to
established guidelines. They may be adapted for individual facility use.
Appendix G. The “Verification of Training Stages for Endoscope Reprocessing” provides an
example of an audit tool to verify that staff training and education have been completed and that
competency with procedures has been established. It may be adapted for individual facility use.

9
Appendix H. The “Guideline for Outbreak Investigation Related to Endoscopic Procedures”
outlines steps to be taken if an outbreak investigation is undertaken. Some steps may be carried
out concurrently and a thorough risk assessment should be conducted to determine if patient
notification is required.
Appendix I. The “PHAC Guideline Rating System” describes the system for ranking the
strength of the evidence used to support the recommendations made in this Guideline.

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PART I. PURPOSE
Decades ago, the advent of flexible endoscopy heralded a new era in diagnostic and therapeutic
medicine; not only was invasive surgery potentially avoidable, but it surpassed the spectrum of
diagnostic and therapeutic options available at the time with rigid bronchoscopes and
esophagoscopes. With improvements in technology, the sophistication and capabilities of these
electro-mechanical devices have further increased, in turn leading to better tolerated and quicker
procedures with less accompanying morbidity and mortality, and more efficient use of resources.
At the same time, however, the complexity of the instruments has presented new challenges in
reprocessing.
Flexible endoscopes are complex instruments with not only an external surface, but also internal
channels (e.g., suction /biopsy, air/water and elevator channels) and accessories that are exposed
to body fluids and other contaminants. These expensive instruments must be designed for reuse.
They are difficult to disinfect and easy to damage because of their intricate design, including
narrow long lumens, and delicate materials. For this reason, policies and procedures must be in
place to ensure appropriate reprocessing of flexible endoscopes before the endoscope is used on
subsequent patients. Research on disposable endoscopes is ongoing. There are some
bronchoscopes that can be steam sterilized but most flexible endoscopes require low
temperatures for disinfection/sterilization.
This document provides guidance for the development of policies and procedures that will
eliminate preventable errors in the reprocessing of flexible endoscopes in all healthcare settings
where endoscopy is performed. The document emphasizes the essential elements required and
methods to be used for the safe handling, transportation and biological decontamination of
endoscopes and their reusable accessories. Definitions used are in accordance with the Canadian
Standards Association(11) and the Public Health Agency of Canada Infection Prevention and
Control Guidelines(12;13).
Robust evidence upon which to formulate these guidelines is scarce as data from randomized
trials are lacking or only preliminary results from clinical trials are available. Thus, these
guidelines largely reflect the efforts of organizations and societies within Canada, Britain and the
USA that have previously published guidelines on reprocessing flexible endoscopes(1;3-9), new
literature, and current published opinions from experts in the field. The appendices of this
document provide examples of audit tools for verification of staff training and competency,
cleaning, disinfection, and safe storage of the equipment, and can be adapted for use as required.
Most reported cases of cross-transmission of infection related to endoscopy have identified
breaches in proper instrument processing or use of defective equipment. It is therefore essential
that all healthcare settings where endoscopy is performed have appropriate guidelines in place
for endoscope reprocessing and handling. Adherence to these guidelines should minimize the
potential for transmission of infection associated with use of the instrument.

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PART II. TRANSMISSION OF INFECTION BY FLEXIBLE
ENDOSCOPY

1. Background

1.1. Spaulding Classification for Medical Devices

In the 1960s, Spaulding developed a system to classify the cleaning, disinfection and sterilization
requirements for equipment used in patient/client care(14). The system divides medical devices
into three categories based on the invasiveness of the procedure that the device will be used for.
The three categories are non-critical, semi-critical, and critical. This classification system is
widely accepted and used by professional organizations(1;4;6;7;15) to help determine the level of
disinfection or sterilization required for various medical devices. Refer to Appendix C for the
Spaulding Classification System and to Appendix B, Glossary of Terms, for definitions. The
recommendations for reprocessing of endoscopes presented here are based on and consistent
with the principles of Spaulding’s classification.

2. Overview
Flexible endoscopic procedures are used for diagnostic (i.e., visualization and sample collection)
as well as therapeutic purposes. The endoscopes that will be discussed in these guidelines are
used for medical conditions involving the lungs (bronchoscopy), the esophagus, stomach and
small intestine (gastroscopy and enteroscopy), the biliary tract and pancreas (duodenoscopy with
endoscopic retrograde cholangiopancreatography (ERCP)), or the large bowel (colonoscopy).
Also included are new modalities that continue to develop and evolve such as combined
ultrasound transduodenoscopy, which provides endoscopic ultrasound to endoscopy (EUS).
Infections related to flexible endoscopic procedures are caused by either endogenous flora (the
patient’s own microorganisms) or exogenous microbes (microorganisms introduced into the
patient via the flexible endoscope and/or its accessories). Microbial sources of infection and
modes of acquisition of exogenous microorganisms causing infection are discussed in detail in
Section 3 of this guideline. The post-procedure infection rate related to inadequate reprocessing
is difficult to determine, as there are no prospective studies that differentiate endogenous from
exogenous infections.
The incidence of infections caused by transmission of microorganisms between patients or from
the environment following endoscopy is estimated to be very low. Twenty-eight reported cases
of endoscopy-related transmission of infection were reported in the United States between 1988
and 1992(16). During that period, approximately 40 million procedures were performed
nationally, with the estimated incidence of transmission therefore in the order of approximately 1
infection per 1.8 million procedures(3;4;8;16). The risk of infection from endogenous sources
ranges from close to 0% with simple upper endoscopy or sigmoidoscopy to slightly greater than
1% in complicated ERCP(17). Although rarely associated with clinical infection, bacteremia with
various gastrointestinal endoscopic procedures is not uncommon. The mean frequency of post-
procedure bacteremia has been reported to range from 0.5% for flexible sigmoidoscopy to 2.2%
for colonoscopy, 4.2% for esophagogastroduodenoscopy (EGD) and 5.6% to11% for ERCP.

12
Performance of biopsy or polypectomy does not change the associated rates of bacteremia.
Esophageal dilatation and sclerotherapy in conjunction with EGD have been reported to raise the
incidence to 45% and 31% respectively(18;19), although recent prospective studies estimate that
bacteremia rates for esophageal dilatation and sclerotherapy may be significantly lower than that,
ranging between 12% and 22%(20).
There is even less information available on infection post-bronchoscopy. The apparent low
incidence might reflect a truly uncommon occurrence, or infections may be under-recognized
because they are easily masked by the primary signs and symptoms for which bronchoscopy is
performed(9). Although pneumonia appears to be a rare complication of bronchoscopy (<1%)(21),
this procedure has been identified as an independent risk factor for healthcare-associated
pneumonia(22). Infections after bronchoscopies are commonly due to mechanical or structural
defects in the device that lead to its inadequate reprocessing(23-25).

3. Microbial Sources

3.1. Endogenous
Endogenous infections after flexible endoscopic procedures arise when the patient’s own
microbial flora gain entry to the bloodstream or other normally sterile body sites as a result of
mucosal trauma or instrumentation and are not related to instrument reprocessing problems.
Examples of endogenous infections include pneumonia resulting from aspiration of oral
secretions in a sedated patient or bacteremia resulting from microscopic tissue trauma occurring
during endoscope insertion or removal.
In the lungs there is normally no resident flora. However, the mucosal surface of the upper
respiratory tract has a substantial load (~ 106 cfu/gm) of microorganisms(26) that can be carried
down into the lower respiratory tract when the insertion tube of the bronchoscope is introduced
into the lung through the mouth. Oropharyngeal microorganisms include a wide range of
viridans streptococci, Moraxella and Neisseria species, and anaerobic bacteria such as
Porphyromonas species, Fusobacterium species and oral anaerobic spirochetes. The stomach
and small intestine have only low levels of resident normal flora (103-6 cfu/gm of tissue)(26), but
again microorganisms from the oropharyngeal cavity and throat can be introduced when the
insertion tube is passed through the mouth into the stomach or small intestine. The large bowel,
on the other hand, has high numbers of normal flora (~ 1012/gram of feces)(26). Microorganisms
found in the colon include anaerobic bacteria such as Bacteroides fragilis, Porphyromonas
species, and Clostridium species as well as high numbers of Enterobacteriaceae (Escherichia
coli, Klebsiella species, Enterobacter species, Proteus species, etc.) and Enterococcus species.
In most immunocompetent patients bacteremia, which may occur during or after procedures, is
usually transient and asymptomatic(19). No published data demonstrate a conclusive link
between procedures of the gastrointestinal (GI) tract and the development of infective
endocarditis (IE) and there are no studies that demonstrate that the administration of antibiotic
prophylaxis prevents IE in association with GI procedures. Therefore, antibiotic prophylaxis
solely to prevent IE is no longer recommended for patients who undergo GI tract procedures,
including diagnostic esophagogastroduodenoscopy or colonoscopy. However, patients with high
risk cardiac conditions (prosthetic heart valve, previous infective endocarditis, certain types of
congenital heart disease and cardiac transplant recipients who develop cardiac valvulopathy) are

13
candidates for prophylaxis before bronchoscopy, only if the procedure involves incision of the
respiratory tract mucosa. For further details, the reader is referred to Prevention of infective
endocarditis: Guidelines from the American Heart Association(27).

3.2. Exogenous
Exogenous infections arise from microorganisms introduced into the patient’s body by the
flexible endoscope or by the accessories used in the procedure and are the focus of this
document. Such infections are preventable with strict adherence to accepted reprocessing
guidelines. Exogenously acquired microorganisms may originate from a number of sources,
which are outlined in Figure 1. These include:

1. A previously used endoscope, followed by inadequate cleaning and/or improper

reprocessing technique.
2. Contamination of the endoscope, accessories, or automated endoscope reprocessor from
the environment during reprocessing (e.g., environmental microorganisms, skin
microorganisms, and water microorganisms).
3. Post-reprocessing contamination of the endoscope and accessories with water,
environmental and/or skin microorganisms during final handling and/or storage.
The reservoir for exogenous microorganisms within a flexible endoscope may be the
suction/biopsy channel or any other channel in the flexible endoscope (e.g., elevator wire
channel in side-viewing duodenoscopes, air/water channel in colonoscopes, or any auxiliary
channels that may be present)(28-32). In addition, the water bottle and tubing used for endoscopy
procedures may also form a reservoir for exogenous microorganisms if these accessories are not
properly reprocessed(33). Components of the reprocessing procedure itself may serve as a
reservoir, such as cleaning brushes if not inspected, cleaned and high level disinfected after each
use; tap water diluted enzymatic detergent and tap water rinse that are not changed after each
use; or if the water filtration system is not maintained as per manufacturers’ instructions(34).
Enzymatic detergent and rinse water used during manual cleaning should be changed for each
scope to ensure residual microorganisms are not introduced into the next endoscope that is
immersed in the used solution. Diluted preparations of enzymatic detergents should never be
stored overnight as tap water-derived microorganisms can multiply to unacceptably high levels.
Tap water used for the final rinse after disinfection/sterilization may result in water
microorganisms being left in the channels(30;35-37). Most guidelines(1;3;4;9;38) now recommend that,
preferably, the final rinse water be sterile, filtered or otherwise rendered free of bacteria. If tap
water is used for the final rinse, flushing the channels with 70-90% alcohol after the rinse is
critical, not only to facilitate drying, but also to help eliminate any residual water
microorganisms introduced from the tap water rinse(37;39).
Bronchoscopic procedures involve substantial flushing of fluid through the biopsy-suction
channel into the lung with subsequent aspiration from the lung back through the endoscope
suction channel and into the side-trap. This “flushing process” through the endoscope channel,
combined with the normally sterile lung environment, results in a higher likelihood of infection
arising from any exogenously introduced microorganisms.

14
This is not to say that upper and lower GI endoscopy have lower rates of exogenously introduced
microorganisms; it simply reflects the higher likelihood that exogenous microorganisms
introduced into the lung in combination with a certain degree of trauma will result in an infection
compared to the same event occurring in the gut.
Figure 1. Acquisition of Exogenous Microorganisms Causing Endoscopy Related Infection

Endoscopic Procedures

Residual environmental
Residual microorganisms from
microorganisms acquired during
previous patient use
reprocessing (e.g., from tap water)

Adequate cleaning/disinfection/sterilization Failure or Inadequate

cleaning/disinfection/sterilization

Wet storage: exposure to environmental

microorganisms Æ overgrowth of bacteria in
wet channels

Flexible endoscope containing residual viable

microorganisms used on next patient

Patient develops an infection due to exogenously introduced

microorganisms

15
4. Specific Microorganisms Transmitted or Shown to Contaminate
Flexible Endoscopes
Bacteria have caused the vast majority of exogenously acquired endoscope-related infections
reported in the literature. The bacteria involved have been either true pathogens, which always
have the potential to cause infection (e.g., Mycobacterium tuberculosis), or opportunistic
pathogens that cause infection if the microbial load is sufficient and/ or host-factors are
permissive (e.g., Pseudomonas aeruginosa).
Transmission of viral pathogens via flexible endoscopic procedures is rare because these
microorganisms are obligate intracellular microorganisms that cannot replicate outside viable
human cells. This means that even if viral particles are present within a flexible endoscope
channel after a patient procedure, the load of viruses cannot increase, as they are not capable of
replication in vitro. Enveloped viruses (e.g., human immunodeficiency virus (HIV), hepatitis B
virus (HBV), hepatitis C virus (HCV)) die readily once dried but non-enveloped viruses (e.g.,
enteroviruses, rotavirus) can survive in dry conditions. Furthermore, enveloped viruses are more
readily killed by high-level disinfectants and/or sterilants compared to non-enveloped viruses.
Viruses can, however, survive longer in the presence of organic material than they can on dry
surfaces. Published studies have demonstrated the efficient removal of HBV and HCV from
endoscopes with standard reprocessing regimens(40;41).
Although there is serious concern about the possibility of HIV transmission by flexible
endoscopes, no cases have been identified. Thorough pre-cleaning has been shown to eliminate
even high titres of HIV, and 2% alkaline glutaraldehyde has been found to inactivate the virus
rapidly, even if the virus is dried in serum on a surface(41-43).
To date, only one case of clinically apparent HBV transmission, from an acutely viremic
hepatitis B patient, via endoscopy has been documented(31). A review of cleaning and
disinfection procedures used at the time this case occurred revealed no breaches in reprocessing
protocol. However, no disinfecting agent was being used to flush the air/water channel and
standardized guidelines for reprocessing endoscopes were not yet available. These factors may
have contributed to the hepatitis B transmission in this situation. A number of studies have
followed patients who were exposed to endoscopes that had recently been used on HBsAg
positive patients, without finding evidence of its transmission to others(44;45).
Eight cases of HCV transmission have now been attributed to gastrointestinal endoscopy(46).
Thorough investigation with genotyping was performed in only three cases, in which
transmission was firmly established by nucleotide sequencing(47;48). While both reports implicate
inadequate disinfection of the colonoscope, they each also raised the possibility of contamination
of syringes or multidose vials as the actual source of transmission. A recent investigation of an
outbreak of acute hepatitis C in patients who underwent procedures at the same endoscopy clinic
revealed that transmission likely resulted from reuse of syringes on individual patients and use of
single-use medication vials on multiple patients at the clinic(49). A multicentre cohort study by
Ciancio et al.(50) followed 8260 HCV seronegative patients who were undergoing endoscopy.
Follow-up serology was performed at 6 months, comparing them with a control population of
healthy blood donors. There were no cases of seroconversion after endoscopy; in particular,
none of the 912 patients who underwent endoscopy with the same instrument previously used on
an HCV carrier showed anti-HCV seroconversion. There were four seroconversions in the

16
control group (indicating a background seroconversion rate of 0.042 per 1000 patient-years).
These results strongly suggest that when currently accepted guidelines are followed, transmission
of HCV does not occur. Other recent studies(51;52) provide further evidence of the safety of
reprocessing protocols based on current accepted standards.
Parasites (e.g., Cryptosporidium sp.) do not replicate in moist environments in the same manner
as bacteria and fungi, but the cysts and eggs of parasites can survive in such environments.
Although there is a theoretical risk of Cryptosporidium cysts and Clostridium difficile spores
surviving high level disinfection (HLD), transmission of such pathogens via endoscopy has not
been reported(3;44). The presence of fungi is associated with prolonged storage of flexible
endoscopes, however, these microorganisms rarely cause infections in immunocompetent
patients. Consequently, although transmission by a contaminated endoscope has
occurred(32;53;54), outbreaks of fungal infection associated with contaminated flexible endoscopes
have been infrequent.
A review article covering the years from 1966 to July 1992(44) reported 281 infections following
gastrointestinal endoscopy and 96 infections following bronchoscopy(44). Microorganisms
associated with transmission of infection from contaminated flexible endoscopes are summarized
in Table 1. Microorganisms associated with transmission, without infection, attributed to
contaminated flexible endoscopes are summarized in Table 2.

17
Table 1. Microorganisms Associated With Transmission of Infection Attributed to
Contaminated Flexible Endoscopes

Organisms Endoscope Type Problem Identified

(55;56)
Helicobacter pylori Duodenoscope Transmission of microorganism to
subsequent patients. Failure to use
appropriate disinfectant between patients.
Pseudomonas 1) Bronchoscopes(24;25) 1) Microorganisms isolated from loose
aeruginosa biopsy port caps due to design flaw,
2) Duodenoscopes(30;39;44;57) resulting in disinfection failure - multiple
cases of cross-transmission.
2) Bacteremias/cholangitis post- ERCP
caused by inadequate disinfection (e.g.,
endoscope flushed with tap water between
patients and no disinfectant used(39),
contamination of inner channels, or
incomplete drying).

Salmonella species Colonoscopes(44;58) Inadequately disinfected colonic biopsy

forceps in one outbreak; in most outbreaks,
disinfectant used was not effective against
Salmonella sp.
N.B.: No reported cases since publication of
cleaning/disinfection standards in 1988.
Enterobacteriaceae 1) Colonoscopes/Duodenoscopes(44) 1) High levels of bacteria within channels -
(range of genera 2) Bronchoscope(24) Transient bacteremia after ERCP.
including: Escherichia 2) Serratia sp. sequestered in loose biopsy
coli, Serratia sp.) port due to design flaw –cross- transmission
to multiple patients (one infection).

Mycobacterium 1) Bronchoscope(59) 1) Failure to disinfect contaminated suction

tuberculosis 2) Bronchoscope(60) valve -cross-transmission to four patients
(one infection).
2) Lack of routine Leak Testing- cross-
transmission to eight patients.
Fungi 1) Duodenoscope(32) 1) Trichosporon beigelii isolated from
2) Duodenoscope(53) biopsy channel after disinfection failure –
cross-transmission to nine patients.
2) T.asahii isolated from tip of endoscopic
forceps and resistant to disinfectant –cross-
transmission to one patient.
Hepatitis C Colonoscope(47) Failure to clean suction channel with brush
and sterilize biopsy forceps- cross-
transmission to two patients who
subsequently developed hepatitis.
Hepatitis B Duodenoscope(31) No disinfecting agent used to flush air/water
channel; standard guidelines not available –
cross- transmission to one patient who
subsequently developed hepatitis.
Strongyloides Duodenoscopes(61) Circumstantial evidence for four cases of
stercoralis cross-transmission of parasite. No further
cases following ETO sterilization.

18
Table 2. Microorganisms Associated With Transmission Without Infection Attributed To
Contaminated Flexible Endoscopes

Organisms Endoscope Type Problem Identified

(62)
Bacillus sp. Bronchoscope Bacillus sp. isolated from suction valves.
Contamination related to improper disinfection and
storage –microorganism detected in bronchial
washing cultures obtained from asymptomatic
patients.

Pseudomonas Bronchoscopes(63) Pseudomonas aeruginosa isolated from suction

aeruginosa channel not cleaned prior to disinfection-
microorganism detected in bronchoalveolar lavage
fluid (BAL) samples from eight asymptomatic
patients.

Mycobacterium sp. 1) Bronchoscopes(64) 1) M. chelonae isolated from lidocaine sprayers used

2) Bronchoscope(65) during bronchoscopy- acid-fast bacilli (AFB) detected
in bronchial washings of asymptomatic patients.
2) M. gordonae isolated from tap water related to
failure in filter replacement and maintenance-AFB
detected in bronchial aspirates of asymptomatic
patients.
Serratia marcescens Bronchoscope(66) Serratia marcescens and Pseudomonas aeruginosa
Pseudomonas isolated from saline used to rinse disinfected scope.
aeruginosa Procedure changed to use filtered water rinse with
scheduled in-line filter changes- microorganism
detected in bronchoalveolar lavage fluid (BAL)
samples from 41 asymptomatic patients.

Fungus 1) Bronchoscope(67) 1) Aureobasidium sp. isolated from re-use of

2) Bronchoscope(54) stopcocks meant for single use in outpatient
bronchoscopy unit –microorganism detected in BAL
cultures from nine asymptomatic patients.
2) B. dermatitidis contamination related to ineffective
mechanical cleaning- microorganism detected in
samples from two asymptomatic patients.
Legionella Bronchoscope(36) Contaminated tap water used to rinse scopes after
pneumophila disinfection. Problem recurred because of inadequate
maintenance to filters –microorganism detected in
BAL samples from three asymptomatic patients.

5. Occupational Infection Related to Endoscopy

Although transmission of infection is rare, endoscopy staff, like the patient, can become infected
as a result of endoscopic procedures. Several studies have examined the prevalence of
antibodies to Helicobacter pylori in the serum of gastroenterologists. Lin et al.(68) found that
endoscopists had a 69% seropositivity rate compared to 40% among internists. Seroprevalence
was similarly higher in two studies comparing endoscopists (about 52%) to blood donors (14-
21%)(69;70). It is unclear whether the subjects wore appropriate personal protective equipment.
In contrast, another study reported no statistically significant difference in seropositivity between
endoscopists and age-matched controls(71). Although differences in methodology may explain
some of the discrepant results, overall it appears that endoscopists do have higher seropositivity
to H. pylori, suggesting that endoscopy can be a risk factor for acquiring H. pylori.

19
Catanzaro described transmission of M. tuberculosis to 10/13 (77%) of healthcare workers
present at the bronchoscopy of an individual with undiagnosed tuberculosis(72). The author
calculated that during bronchoscopy and intubation of the patient, at least 249 infectious
units/hour of mycobacteria were generated. One case of bacterial conjunctivitis from a splash
during colonoscopy has been reported, highlighting the need for appropriate personal protective
equipment(73).

6. Classic and Variant Creutzfeldt-Jakob Disease

Transmissible spongiform encephalopathies (TSEs) are caused by prions, which are protein
particles that contain no nucleic acid, yet are capable of causing a transmissible disease. All
prions are hardy, remain infectious for years in a dried state, and resist all routine sterilization
and disinfection procedures commonly used by healthcare facilities(74-78). Differences in the
pathogenesis of classic (sporadic, familial and iatrogenic) Creutzfeldt-Jakob Disease (CJD) and
variant Creutzfeldt-Jakob Disease (vCJD) are reflected in the different distribution of TSE-
specific protein (PrPTSE) in the bodies of patients with CJD versus vCJD. This means that
different infection prevention precautions may be required during endoscopic procedures in
patients with vCJD as compared to patients with classic CJD.
In classic CJD, prion infectivity is largely limited to the central nervous system (CNS) and only
surgical instruments contaminated with prions from these high-risk tissues have resulted in
iatrogenic transmission. In classic CJD, PrPTSE is found less often in organs outside the CNS,
such as the lung, spleen, and lymph nodes and these tissues are considered to have low
infectivity. Much of the evidence for this conclusion comes from studies of the distribution of
the abnormal prion protein and/or associated prion infectivity in tissues of individuals with prion
diseases. The agent responsible for vCJD is different from the agent that causes sporadic CJD.
With vCJD, PrPTSE has been detected in a number of lymphoid tissues, as well as the intestinal
tract and these tissues are considered to have a higher level of infectivity than similar tissues in
patients with classic CJD. Experimental evidence suggests that the lymphoreticular system may
contain significant levels of infectivity for most of the incubation period (mean 10-30 years). To
support this, PrPTSE was found in the germinal centres of an appendix that was removed eight
months before the onset of neurological disease in a patient with vCJD. Lymphoid follicles and
germinal centres are widely distributed in the gastrointestinal tract and are often biopsied; it is
therefore possible that endoscopy on patients who have or are incubating vCJD may result in
contamination of the instrument (and particularly the biopsy forceps) with PrPTSE(79).
In a patient with vCJD, an endoscope can potentially be contaminated with PrPTSE at several
points during an endoscopy procedure. During upper GI endoscopy and bronchoscopy, the first
potential point of contamination is the tonsils if they are traumatized during insertion of the
scope. If a small bowel biopsy deep enough to encounter lymphatic tissue is obtained, it is
possible to contaminate the biopsy/suction channel as the biopsy forceps are withdrawn. The
biopsy channel is an issue with lower GI tract endoscopies if biopsies are obtained. An ileal
biopsy is a higher risk procedure than duodenum or jejunum biopsy because of the higher
concentration of Peyer’s patches in the ileum(80).
With classic CJD, since PrPTSE has not been found in the GI tract, GI endoscopy alone is unlikely
to be a vector for its transmission.

20
Although lung and lymphoid tissues have been identified as low infectivity for CJD, the
magnitude of infectivity is such that special precautions related to the procedure and
reprocessing of equipment are not required(7;75;76).
Disinfection techniques to eliminate prion infectivity include prolonged steam sterilization, and
extended soaks in concentrated sodium hydroxide, sodium hypochlorite, or formic acid(81)
(Please refer to Public Health Agency of Canada Infection Prevention and Control Guideline:
Classic Creutzfeldt-Jakob Disease in Canada , Quick Reference Guide-2007(75) and Classic
Creutzfeldt-Jakob Disease in Canada (www.phac-aspc.gc.ca/piblicat/ccdr-
rmtc/02vol28/28s5/index.html)(75;76;80). Unfortunately, an endoscope cannot be reprocessed by
any of these techniques without sustaining severe damage(81). Therefore, endoscopes used on
patients with vCJD must be single use or destroyed after use(7).
The risk of transmission of any pathogen from an endoscope depends on many factors including
the susceptibility of the exposed individual, the infectivity load of the tissues, the amount of
contaminating tissue (in part related to the type of procedure done) and the effectiveness of the
decontamination processes(82). The quantification of risk from asymptomatic individuals
depends on the prevalence of disease. The total number of cases of vCJD reported in the UK,
since 1990, was 166 as of December 31st, 2009 (www.cjd.ed.ac.uk/figures.htm) and 211
worldwide(81). The risk in Canada is much lower than in the UK as reflected by only a single
case reported to date(83). This case occurred in 2002 and infection was likely acquired while the
individual was living for a period of time in the United Kingdom. The transmission of CJD and
vCJD via an endoscopic procedure, remains only a theoretical risk at this time, as no cases of
such transmission have been reported(46;80).

7. Factors That Contribute to Survival of Microorganisms in Reprocessed

Flexible Endoscopes

7.1. Wet Storage

Bacteria may replicate to substantive levels even after overnight storage at room temperature if
there is adequate moisture in the endoscope channels. Some bacteria can survive drying (e.g., M.
tuberculosis and Gram positive bacteria) whereas others, like Gram negative bacteria (e.g., P.
aeruginosa and E. coli), die rapidly when dried. Gram negative bacteria replicate more easily in
the presence of moisture and have been implicated in endoscope associated infections more
frequently than have Gram positive bacteria(29).
Moisture remaining in the channels of flexible endoscopes is a major contributing factor to
exogenous microorganisms being transmitted by flexible endoscopes and outbreaks related to
inadequate drying and improper storage have been reported(30;37). A survey by Kazmarek et al. in
1991(84) of stored flexible endoscopes found that 23.9% of samples taken from the devices’
channels had > 105 cfu/channel. Alfa & Sitter 1991(29) demonstrated that overgrowth of bacteria
in flexible endoscope channels during storage was most commonly associated with Gram
negative organisms, rather than Gram positive organisms. Ensuring the endoscope channels are
thoroughly dried can prevent this overgrowth.

21
 7.2. Biofilm Formation and Organic Debris
The ability of bacteria to form biofilms is an important factor in their potential to cause
endoscopy-related infections. During clinical use blood, feces, mucus, and other biological
substances can adhere to the endoscope and its channels. If the channels are not properly
cleaned, there may be high residual levels of organic material and microorganisms(85-89). If the
endoscope remains moist for extended periods, the residual bacteria can produce biofilm.
Biofilms consist of colonies of microorganisms forming structures to maximize growth potential.
Development of a biofilm begins when free-swimming bacteria attach to a surface. Substantial
biofilm formation may result after overnight storage(90). Microorganisms embedded within this
biofilm are sheltered from the cidal activity of the disinfectant/sterilant. This protection is
further enhanced if there is residual organic material post-cleaning; subsequent exposure to
aldehyde based disinfectants leads to fixation of the matrix, but the microorganisms within the
matrix (i.e., biofilm and/or residual patient secretions) may or may not be adequately
killed(4;80;91). Additionally, biofilm formation explains why flexible endoscopes should not be
left soaking in enzymatic detergent overnight. Enzymatic detergents do not inhibit bacterial
replication, and indeed, the microorganisms can use the enzyme proteins as an energy source.
Therefore the most important step in endoscope reprocessing is bedside flushing, with
subsequent manual cleaning and brushing of endoscope channels, as soon as possible after the
procedure. This will reduce the likelihood that residual organic material or bioburden will be
present during the disinfection/sterilization stage. The importance of timely flushing, and
manual cleaning and brushing, cannot be overemphasized(92).

7.3. Equipment Design Flaws

Two studies(24;25) confirm that design flaws can contribute to, if not promote, microbial
contamination despite adherence to proper reprocessing protocols. In both reports, the
documented design flaw was a faulty biopsy port in a bronchoscope that could loosen, allowing
patient secretions and microorganisms to become sequestered in a moist environment,
inaccessible to adequate cleaning and disinfection. The problem was identified when an
abnormally high rate of P. aeruginosa was detected in bronchoalveolar lavage (BAL) specimens.
This illustrates how periodic review of microbiology reports from BAL samples may be a useful
audit tool for bronchoscopy services. Such audits would not be possible for duodenoscopy and
colonoscopy as cultures are generally not done as a part of these procedures. Correcting design
flaws is beyond the ability of most endoscopy units and primarily the responsibility of
manufacturers of equipment and their regulatory bodies. However, endoscopy users may be able
to identify flaws that manufacturers should address.

8. Errors in Reprocessing
Outbreaks associated with flexible endoscopy have most often been associated with breaks in the
cleaning and/or disinfection/sterilization stage of flexible endoscope reprocessing(92). Cowan(45)
has described how the currently used reprocessing protocols provide a very narrow margin of
safety and any slight deviation from the recommended steps may result in an increased risk of
infection transmission by flexible endoscopes. Tables 1 and 2 show that errors in reprocessing of
flexible endoscopes are the most common underlying problems associated with endoscopy-

22
related transmission of infection. Some of the most common errors associated with reprocessing
of flexible endoscopes have been identified by surveys of endoscopy units(84;93) and include:
• Failure to perform leak testing prior to cleaning,
• Failure to completely immerse scope during cleaning,
• Inadequate exposure time to enzymatic detergent during cleaning,
• Inadequate amount of active ingredient used for disinfection,
• Inadequate volume of water used for rinsing,
• Inadequate time for scope drying prior to storage, and
• Placement of the valves on the endoscope during storage.
In addition to these breaches in reprocessing, a Canadian survey reported that few healthcare
facilities (30%) had written instructions for reprocessing of flexible endoscopes in their
facility(93). The introduction of Minimum Effective Concentration (MEC) testing of liquid
chemicals (LC) has reduced the problem previously associated with an inadequate level of active
ingredient due to inactivation or dilution.
Barriers to the proper reprocessing of flexible endoscopes are both the lack of appropriate initial
training and of ongoing competency assessment for staff performing the reprocessing. A
checklist that can be used to ensure competency of staff in the flexible endoscope reprocessing
area has been included in Appendix G.

23
PART III. FLEXIBLE ENDOSCOPES: STRUCTURE and FUNCTION
Endoscopes are very complex biomedical devices. The complexity results from the need for
fiberoptic bundles and multiple long narrow channels to be contained within a tubular structure
that is constrained by the limited dimensions of the body cavity opening (e.g., throat, intestine,
trachea). The endoscope is only one element of the system. Other required elements are a light
source, video processor, monitor and water bottle. For the purpose of describing an endoscope in
these guidelines, we will refer to videoscopes, which represent a newer technology in endoscope
development as compared to fiberoptic endoscopes. In videoscopes, the “viewing” fibre bundle
is replaced by a miniature charged coupled device (CCD) video camera chip that transmits
signals via wires. Certain endoscopes, particularly very narrow endoscopes used for direct
viewing of the bile and pancreatic ducts, remain fiberoptic and require the same care in handling
and reprocessing as videoscopes. Endoscopes that are not completely immersible are no longer
acceptable. Videoscopes consist of three major sections: the connector section (sometimes
referred to as the “umbilical” section), control section and the insertion tube. Endoscopes require
a watertight internal compartment integrated through all components for electrical wiring and
controls, which protects them from exposure to patient secretions during use and facilitates the
endoscope being submerged for cleaning and subsequent disinfection.
The connector section (see figure 2.) provides connections for four systems:

1. Electrical System (figure 2. part 14): A cable with video signal, light control, and remote
switching from the video processor is connected here. A watertight cap is required for leak
testing and reprocessing. The electrical connector is the only opening to the internal
components.
2. Light System (figure 2. part 12): The connector is inserted into the light source and directs
light via the fiberoptic bundle in the light guide to the distal end of the insertion tube.
3. Air and Water System (figure 2. part 13): Air pressure is provided from a pump to the air
pipe, and the water bottle is also connected here (there is no water channel or water
connection for bronchoscopes). In some endoscope models, the separate air and water
channels merge just prior to the distal end where they exit through a single channel. In
other models, the air and water channels are totally separate and do not merge. The air and
water channels are usually of 1mm internal diameter (I.D.), which is too small for
brushing.
4. Suction System (figure 2. part 11): Portable or wall suction system is connected to the
suction port. The Universal cord encases the electrical wiring and air, water and suction
channels from the connector to the control section. Teflon® (PTFE) tubing is commonly
used for channels, and advances in technology have led to more pliable and smooth
materials for instrument channels with better anti-adhesion properties. The suction channel
size can vary from 2mm to 4mm I.D. depending on scope make and model. There is a
biopsy port (figure 2. part 9) on the side of the insertion tube that allows instruments to be
passed down the insertion tube to the distal end (referred to as the instrument channel or
biopsy/suction channel).

24
The control section (figure 2. parts 1-6, 8, 9, 16) has moveable knobs that allow the physician to
control all scope functions. The angulation control knobs drive the angulation wires and control
the bending section at the distal end of the insertion tube, thereby providing two-dimensional
angulation. Locking mechanisms are provided to hold the bending section in a specific position.
The suction cylinder and valve connects the suction channel to the instrument channel in the
insertion tube. By pressing the valve button, suction can be provided to the instrument channel.
The air/water cylinder and valve are similar to the suction cylinder/valve except that a two-way
button valve is used in a dual channel cylinder thereby providing air or water to the lens at the
distal end to wash and insufflate for better vision. Both valves are removable for cleaning. The
air and water channels also require a cleaning adaptor valve that is to be used at the end of each
procedure. Insertion of the cleaning adaptor initiates air flow through both air and water
channels, and once activated, water is pumped through both channels. The instrument channel
port (often referred to as the “biopsy port”) is located on the lower part of the control section. It
enters the instrument channel at a Y-piece union with the suction channel. A valve is required to
close the port so that suctioning may be facilitated. Remote switches present on the top of the
control section are usually programmable, allowing control of the video processor (i.e., contrast,
iris and image capture functions).

25
Figure 2. Components of a Flexible Video Endoscope

26
Furthermore, some models have unique features that facilitate specific therapeutic applications.

Table 3. Examples of Specifications For Flexible Endoscopes

INSERTION TUBE O.D. INSTRUMENT CHANNEL I.D.
SCOPE TYPE WORKING LENGTH
(outer diameter) (internal diameter)

Adults

GASTROSCOPE 9.0 mm-11.4 mm 1030 mm-1050 mm 2.8 mm-3.8 mm

DUODENOSCOPE 10.8 mm-12.5 mm 1235 mm-1250 mm 3.2 mm-4.2 mm

COLONOSCOPE 12.9 mm-13.7 mm 1330 mm-1680 mm 3.7 mm-4.2 mm

SIGMOIDOSCOPE 12.8 mm-13.2 mm 700 mm-730 mm 3.7 mm-4.2 mm

ENTEROSCOPE 10.5 mm-11.7 mm 2200 mm-2500 mm 2.8 mm-3.8 mm

BRONCHOSCOPE 5.7 mm-6.0 mm 550 mm-600 mm 2.0 mm-2.8 mm

Pediatrics

GASTROSCOPE 5.9 mm-6.0 mm 1030 mm-1050 mm 2.0 mm

COLONOSCOPE 11.5 mm-11.6 mm 1680 mm-1700 mm 3.2 mm-3.8 mm

BRONCHOSCOPE 4.4 mm-5.1mm 600 mm 2.0 mm

NB. Ranges of flexible endoscope manufactured by Olympus and Pentax, including diagnostic
and therapeutic models are included in this table. These are provided as examples only and
are not intended as an endorsement of a specific manufacturer’s product.
Duodenoscopes have two unique features: a side viewing charged coupled device and an
elevator lever that can manipulate an instrument at the distal end without moving the bending
section. A cable system (elevator wire) connected to a lever at the angulation knobs in the
control head is required for control. The cable is an ‘external’ component that is exposed to
patient secretions during use. It is inside a separate channel that extends from the control head to
the distal end. It is important that this channel is properly cleaned and disinfected after each use.
Access to this channel is through the elevator wire port. The small inner diameter of this channel
combined with the wire inside requires greater pressure to push fluids through this channel
compared to the other channels. Some specialized therapeutic endoscopes such as the ultrasound
endoscope may also have an elevator channel, which requires additional steps for manual
cleaning and disinfection.

27
Therapeutic gastroscopes and colonoscopes provide options for auxiliary water channels or
secondary instrument channels, each creating additional steps in the cleaning and reprocessing
procedures. Therapeutic gastroscopes may have double therapeutic channels, each needing to be
brushed, cleaned and disinfected. They may require additional adapters in order to effectively
disinfect the endoscope.
Bronchoscopes have only an up-down angulation lever for one dimensional control of the
bending section and they do not have an air water channel. Ancillary equipment required for the
video system includes a video processor, monitor and light source. The video processor is solely
for handling the signal from the CCD chip and this enables control for color, contrast, image
enhancement and light intensity control. The light source commonly uses a 300-watt xenon
lamp and provides the pump for the air/water system.

28
PART IV. ISSUES RELATED TO REPROCESSING FLEXIBLE
ENDOSCOPES

1. Reprocessing of Flexible Endoscopes and Accessories

The complexity and temperature sensitivity of flexible endoscopes makes cleaning followed by
sterilization/disinfection difficult. While sterilization may be optimal, the minimum acceptable
standard for reprocessing endoscopes is high level disinfection (HLD). At all times, cleaning
must precede high level disinfection. Endoscopic accessories do require sterilization.
Whenever flexible endoscopes are reprocessed, those involved in the reprocessing must adhere
to the validated protocol recommended by the manufacturer of the endoscope. Table 4 provides
detailed instruction, based on national and international guidelines, regarding both the specific
steps and rationale for cleaning, disinfection, rinsing, drying and storage of endoscopes,
regardless of the type/model. Figure 3 is a flow chart of the reprocessing steps described in
Table 4.

29
 TABLE 4. Critical Steps for Reprocessing Flexible Endoscopes(36;93-98)
NOTE: The following table is a summary guide of the critical steps for the reprocessing of flexible endoscopes. Please refer to the reprocessing manual provided by the
manufacturer for each endoscope being reprocessed. Different types and models of endoscopes may require additional steps or different procedures to properly reprocess the
device.
Personal protective equipment should be worn at all times during reprocessing.

STEP OR PROCEDURE RATIONALE BARRIERS TO ADEQUATE REPROCESSING

Pre-Cleaning (Immediately after use in procedure room)

1. Wipe down the insertion tube of the endoscope with
Reduces risk of worker and/or environmental
a soft lint-free disposable cloth or endoscope sponge
contamination.
soaked in freshly prepared enzymatic detergent.
2. Flush the air/water channels as per the manufacturer
of the endoscope. Flush all other channels with Removes gross debris and ensures patient material is The correct adaptors are to be used in order to properly flush all
enzymatic detergent solution at bedside immediately not allowed to dry, which will impair reprocessing. channels according to manufacturer’s instructions.
post procedure, followed by air.
3. Remove all detachable parts (e.g., valves) and
reprocess accordingly. Attach the water resistant
Prevents patient material from drying on scope and Reprocessing done off-site; may have long transit time so that
cap, if appropriate. Transport in a covered container
prevents environmental contamination. secretions dry on device.
rapidly to reprocessing area before drying of patient
material occurs
Leak Testing
4. Perform leak testing as per manufacturer’s
Patient material can enter scope housing and will not be accessible
instructions. If leaks are present, subsequent cleaning will allow
to cleaning; sequestered soil inhibits disinfection; the residual soil
Note: If a leak is detected, the endoscope must be fluid to enter the scope housing and cause damage.
acts as a source of contamination if scope used on another patient.
repaired. Follow manufacturer’s instructions.
Manual Cleaning & Rinsing
1) Scope is not completely immersed, cleaning is not as well done.
2) Contact time with the enzymatic detergent is not adequate.
3) Full reprocessing of the endoscope is not completed promptly.
Enzymatic detergent improves cleaning ability by
If patient-used endoscopes are allowed to soak in enzymatic
5. Completely immerse scope in enzymatic detergent breaking down proteins. Immersion reduces aerosols,
detergent or remain wet overnight, this will facilitate biofilm
solution. thereby reducing the infectious biohazard risk to
formation.
reprocessing staff.
4) The enzymatic detergent is not properly diluted or the required
temperature for activation of the product is not respected, which
can lead to inadequate product performance.

30
 STEP OR PROCEDURE RATIONALE BARRIERS TO ADEQUATE REPROCESSING
Inadequate brushing leads to residual patient material that can
6. Clean all exterior surfaces of the endoscope using a
cause disinfection failure and lead to disease transmission between
soft lint-free cloth or endoscope sponge while
patients.
keeping the endoscope immersed. Use endoscope
Brushing greatly improves the efficiency of the Ensure that the brush used is appropriate for the type of endoscope
brushes to clean ALL channels while the scope is
cleaning process. and that the diameter of the bristle is adequate for the diameter of
immersed. (NOTE: not all channels can be brushed -
the channel. Inappropriate brushes may not dislodge biological
follow manufacturer’s recommendation for channel
materials or may damage the inside of the channels. Refer to the
cleaning). Repeat until all debris has been removed.
manufacturer of the endoscope for specifications of the channels.
7. Use manufacturer’s cleaning adaptors to ensure
adequate enzymatic detergent is flushed through If a channel is blocked, fluid will flow preferentially through other
ALL channels (including the elevator wire, forward Residual material in any channel can pose a risk for channels. Therefore, ensure fluid is flowing through all channels.
jet, 2nd therapeutic channel, balloon channel), and transmitting infectious material to the next patient. The preferred method of flushing the instrument is from umbilical
soak in enzymatic detergent as directed by the end to distal end.
manufacturer of the enzymatic detergent.
Adequate removal of detergent is not achieved when an
8. Remove the endoscope from the enzymatic detergent The enzymes are proteins and if not adequately rinsed insufficient amount of rinse water is used or with used rinse water.
basin and place in a basin filled with clean water for off, can contribute to protein build-up within scope The pre-rinse cycle of some Automated Endoscopy Reprocessors
rinsing channels. (AERs) can be used to ensure the appropriate volume of rinsing is
achieved.
9. Rinse all channels with an adequate volume of water
to remove all detergent (At a minimum use Adequate removal of detergent is not achieved when an
The enzymes are proteins and if not adequately rinsed
approximately three times the total channel volume insufficient amount of rinse water is used. The pre-rinse cycle of
off, can contribute to protein build-up within scope
specific to the endoscope being reprocessed. Ensure some AERs can be used to ensure the appropriate volume of
channels.
a copious amount of water is used to remove all rinsing is achieved.
enzymatic detergent).
10. Following the rinse, purge all endoscope channels
A high level disinfectant diluted with residual water may reduce
with air to ensure removal of water. Wipe the Residual water will dilute the high level disinfectant
the efficacy of the disinfectant and not properly disinfect the
exterior surfaces of the endoscope using a soft lint- and reduce the concentration of the disinfectant.
device.
free disposable cloth to remove excess moisture.
High-Level Disinfection
11. Monitor minimal effective concentration (MEC) of
The high level disinfectants that are reused can lose
the high level disinfectant or sterilant if reused. Lack of monitoring can result in use of ineffective high level
efficacy through excessive dilution and/or
Rapid test strips specific to the product being used disinfectant concentrations and inadequate microbial killing.
inactivation.
are available for this purpose.

31
 STEP OR PROCEDURE RATIONALE BARRIERS TO ADEQUATE REPROCESSING
12. Completely immerse the endoscope in a dedicated
basin filled with an approved high level disinfectant
or sterilant as per manufacturers’ instructions. Use
the endoscope cleaning adaptors to fill ALL channels
with adequate high level disinfectant or sterilant
(including the elevator wire, forward jet, 2nd
therapeutic channel, balloon channel), and soak in
the high level disinfectant or sterilant as directed by
the manufacturer of the product. Wipe the
Microbial killing needs to be effective; therefore, only
endoscope with a soft lint-free cloth to remove any Disinfectants other than those approved may result in inadequate
disinfectants with antimycobacterial activity (e.g.,
bubbles on the surface of the endoscope. (NOTE: If microbial killing.
high level disinfectant) or sterilants are appropriate.
an AER is used for reprocessing Endoscopic
Retrograde Cholangiopancreatography (ERCP)
scopes or other specialty endoscopes, ensure that
all channels can be disinfected by the AER.
Otherwise the affected channels MUST be
manually cleaned/disinfected prior to placing in
the AER).

Problems with adequate timing are frequent when manual

13. Adequate contact time and temperature are critical;
disinfection is done because timing of exposure to a high level
therefore, temperature of the product should be
If less than the minimum effective exposure time or disinfectant is often not performed. This is not an issue with AERs
monitored and contact time should be timed
temperature are used, microorganisms may survive. as long as the AER is programmed according to the manufacturer
accurately as per manufacturer’s recommendations.
This increases the risk of transmitting infections. of the high level disinfectant or sterilant instructions.
The use of a timer should be considered.
Temperature requirements still need to be respected while using
an AER.
14. Following the disinfection, purge all channels with
air to ensure removal of all high level disinfectant or The correct adaptors are to be used in order to properly flush air
Residual high level disinfectant and sterilants can
sterilant from the endoscope and remove the through all channels according to manufacturer’s instructions to
cause tissue damage(99).
endoscope from the high level disinfectant or remove all high level disinfectant or sterilant from the endoscope.
sterilant.
Rinsing

32
 STEP OR PROCEDURE RATIONALE BARRIERS TO ADEQUATE REPROCESSING
15. Immerse the endoscope in a dedicated basin filled
with fresh bacteria-free or sterile water. Rinse all
channels with an adequate volume of water to
remove all high level disinfectant or sterilant (at a
minimum use approximately three times the total Problems with inadequate rinsing are possible when manual
channel volume specific to the endoscope being disinfection is done. Different endoscopes may require larger
Residual high level disinfectant and sterilants can
reprocessed. Ensure a copious amount of water is rinsing volume than others. Because the rinse volume in an AER
cause tissue damage(99); therefore, adequate rinsing is
used to remove all high level disinfectant or is usually preset and cannot be reduced by the user unless initially
critical to remove all residuals.
sterilant). Refer to the high level disinfectant or programmed incorrectly, AERs provide more reliable rinsing,
sterilant manufacturer’s recommendations for compared to manual methods where user variability is a problem.
appropriate rinsing procedure. Some high level
disinfectant or sterilants require several complete
water exchanges. Most AERs rinse with several
litres of water.
Tap water can contain Mycobacteria, Pseudomonas
16. Final rinse water should be sterile or bacteria-free. and other microorganisms. Therefore, the final rinse
Bacterial overgrowth within flexible endoscope channels may
Tap water can be used, but if it is, a subsequent 70- water should be bacteria-free (i.e., filtered through a
result from tap water microorganisms in moist channels. This has
90% alcohol rinse is CRITICAL between each patient 0.2 µm filters). Filtration can produce bacteria-free
led to infection transmission between patients.
use and prior to storage. water provided there are no viruses in the water being
filtered and the filters are patent.
Drying
17. Remove the endoscope from the rinse water and
purge all channels with air to remove all remaining
rinse water. Rinse all channels with 70% - 90 %
This facilitates the drying of the channels and will
alcohol (approximately 60 ml. flushed through all Lack of drying has been associated with infection transmission
also kill any tap water microorganisms that might be
channels using the appropriate adaptors). between patients due to microbial overgrowth.
present.
(NOTE: alcohol rinse and drying is not needed if scope
is used immediately on another patient, unless the
final rinse was with unfiltered tap water)
Lack of drying has been associated with infection transmission
18. Following the alcohol rinse and prior to storing the
between patients due to microbial overgrowth.
endoscope, purge all channels with forced air. Wipe
This facilitates the drying of the channels. High pressured air (compressed air) may damage the inner
the exterior surfaces of the endoscope with an
structures of the endoscope. Consult the manufacturer of the
alcohol moisten soft lint-free cloth.
endoscope for more information.
19. Store endoscope uncoiled in a vertical position (i.e.,
Keeping valves on during storage increases the risk that residual
hang in closed, ventilated cabinet). Store detachable This facilitates drying of the scope during storage and
moisture will remain, increasing the risk of microbial overgrowth
and reusable parts (e.g., valves and water resistant reduces risk of recontamination.
and infection.
cap) separately from scope.

33
 Figure 3. Flow Chart for Endoscope Reprocessing

High Level Disinfection &

Pre-Cleaning Leak Testing* Manual Cleaning & Rinsing Drying & Storing
Rinsing

Fully immerse the

Fully immerse the
Test High Level endoscope in dedicated
Cleaning outer surface Attach leak tester* endoscope in
Disinfectant or sterilant* basin filled with rinse
enzymatic detergent
water

Fully immerse endoscope Rinse all channels with

in HLD or sterilant in rinse water**
Ensure the endoscope is Clean outer surface
fully immersed in water. dedicated basin
with lint free cloth
Do not use any detergent or endoscope sponge
Flush the air/water Remove the endoscope
channel* Fill all channels
with HLD or sterilant and from the rinse water and
wipe the endoscope with purge all channels
a soft lint-free cloth to with air **
Perform leakage test. remove any bubbles on
Brush all appropriate
Perform complete the surface of the
channels*
manipulation endoscope*
of buttons and lever Purge all channels
Flush all other channels with alcohol followed
with enzymatic detergent with forced air as
Ensure adequate contact indicated***
Flush all channels with
with all surfaces of the
enzymatic detergent and
endoscope*
Ensure deflation of the ensure appropriate
endoscope before contact time is respected*
proceeding to the manual Wipe the exterior surfaces
cleaning of the endoscope with an
Remove all reusable and Ensure adequate contact
alcohol moisten soft lint-
removable components time and right
Immerse in clean water free cloth
from the scope and soak Temperature is
in enzymatic detergent* and rinse all channel with respected*
clean tap water*

Store endoscope uncoiled

in a vertical position (i.e.,
Purge all channels with
hang in closed, ventilated
Install the water resistant air to ensure removal of
Purge all endoscope cabinet). Store
cap and transport in a all HLD or sterilant from
channels with air to detachable and reusable
covered container to the endoscope and
ensure removal of water * parts (e.g., valves and
reprocessing area* remove the endoscope
water resistant cap)
from the HLD or sterilant
separately from scope.

** As
Asper
per manufacturer
manufacturer of
ofthe
theproduct
product
**
** As
Asprescribed
prescribed by
bythe
themanufacturer
manufacturer of
ofthe
the High
High Level
Level disinfectant
disinfectant AND
ANDinin accordance
accordancetoto the
themanufacturer
manufacturerof ofthe
theendoscope
endoscope
***
*** Alcohol
Alcohol rinse
rinseand
anddrying
dryingis
isnot
notneeded
neededififscope
scopeis
isused
usedimmediately
immediatelyononanother
anotherpatient,
patient, unless
unless the
the final
final rinse
rinse was
waswith
withunfiltered
unfilteredtap
tap water
water

34
 1.1. Pre-Cleaning
Meticulous manual cleaning of endoscopes and accessories is critical to the success of
subsequent disinfection or sterilization. Manual cleaning refers to the physical removal of
organic material and/or soil. The presence of residual organic material and/or soil may protect
microorganisms from penetration and destruction by germicides, therefore contributing to
disinfection or sterilization failure.
The initial steps in the cleaning process begin immediately after the patient procedure to prevent
drying of secretions on both the exterior surface and inner channels of the endoscope(9;15). At the
conclusion of the procedure, and before transporting the endoscope to the reprocessing area, the
following steps need to be performed:
• Wipe the insertion tube with a soft lint-free cloth or endoscope sponge
soaked in freshly prepared enzymatic detergent.
• Flush the air/water channels as per the endoscope manufacturer’s
instructions.

• Flush all other channels with enzymatic detergent solution at bedside

immediately after the procedure, followed by flushing with air.
• Flush all the internal channels with freshly prepared enzymatic detergent to
moisten and dilute organic debris.
• Remove all detachable parts and have them reprocessed accordingly.
• Attach the water resistant cap (if indicated).
• Immediately transport in a covered container to the reprocessing area.

1.2. Leak Test

The goal of performing a leak test is to detect any physical breaks to
the exterior or interior of the endoscope(4;60). These physical breaks
compromise the integrity of the endoscope and will damage the
internal structures (i.e., electrical wires, light bundle, manipulation
cables) of the endoscope, which are not meant to be in contact with
fluids. These breaks may also create a reservoir for microorganisms to proliferate(4). Leak
testing should be done after each procedure and prior to manual cleaning.
A leak test is performed by applying air pressure to the inside of the endoscope and by
monitoring the presence of air bubbles coming from the endoscope(4) or by the inability to
maintain adequate air pressure within the endoscope.

35
If a leak is detected, immediately remove the endoscope from service and have the device
repaired or replaced. Refer to the manufacturer's instructions for proper decontamination and
transportation of broken endoscopes. Always perform leak tests as per the manufacturer’s
instructions(4;60).

1.3. Manual Cleaning and Rinsing

Manual cleaning of flexible endoscopes is prone to error and

must therefore be done with care.

A problem that may be encountered by the reprocessing staff is unfamiliarity with all of the
channels for the particular model of flexible endoscope being reprocessed. This highlights the
need for staff training and ongoing competency testing and quality assurance. It is useful to have
diagrams of type/models being reprocessed in the healthcare facility that clearly identify all the
channels that must be cleaned and disinfected.
The enzymatic detergent used for cleaning flexible endoscopes (follow the manufacturer’s
recommendations for reconstitution and application) is a protein solution, and therefore if rinsing
is not adequate after the cleaning process, there will be residual detergent protein remaining. If
an inadequately rinsed endoscope is then placed in an aldehyde disinfectant, the residual
detergent protein will be “fixed” within the channels and on the surface of the endoscope,
possibly protecting underlying bacteria from exposure to the disinfectant.
• After successfully carrying out the leak test, completely
immerse the endoscope in a freshly prepared enzymatic
detergent solution (prepared as per the manufacturer's
instructions).
• Clean all exterior surfaces of the endoscope using a soft lint-
free cloth or endoscope sponge while keeping the endoscope
immersed.
• Use endoscope brushes to clean ALL channels while the scope is
immersed. (NOTE: not all channels can be brushed - follow the
manufacturer’s recommendations for channel cleaning). Repeat until all
debris has been removed. Flexible endoscopes have multiple channels
with different diameters, so it is essential that a variety of brushes be
available for use. Brushes should be of the correct diameter and length
to ensure that the bristle will make contact (provide friction) with the
walls of the lumens.
• Use the manufacturer’s cleaning adaptors to ensure adequate enzymatic
detergent is flushed through ALL channels (including the elevator wire,
forward jet, 2nd therapeutic channel, balloon channel), and soak in
enzymatic detergent as directed by the manufacturer of the enzymatic
detergent.

36
• Remove the endoscope from the enzymatic detergent basin and place in a basin filled with
clean water for rinsing.
• Rinse all channels with an adequate volume of water to remove
all detergent (At a minimum use approximately three times the
total channel volume specific to the endoscope being
reprocessed. Ensure a copious amount of water is used to
remove all enzymatic detergent). The use of potable tap water
for rinsing after endoscope cleaning is acceptable.
• Following the rinse, purge all endoscope channels with air to ensure removal
of water. Wipe the exterior surfaces of the endoscope using a soft lint-free
disposable cloth to remove excess moisture.

All channels should be brushed and rinsed prior to

disinfection(1;3;6;21;47;64;100).

Ideally, cleaning and disinfection of endoscopes should be performed immediately after use.
There may be instances where this is difficult to achieve (e.g., emergency procedures after
hours). If immediate cleaning is not possible, the endoscope may be flushed and soaked in an
enzymatic detergent solution until properly reprocessed(101). If the endoscope has been cleaned,
but not disinfected, and left to soak, it should be thoroughly cleaned again prior to disinfection.
If flexible endoscopes are inadvertently left overnight prior to cleaning, the manual cleaning
stage must be performed thoroughly prior to disinfection/sterilization. As outlined in the
previous discussion on biofilm formation, allowing a flexible endoscope to sit overnight with
residual microorganisms and patient secretions in the channels will lead to biofilm formation that
may be difficult to subsequently remove. Consult the manufacturer of the endoscope for special
directives on delayed reprocessing.
Few published studies address whether washing by the automated endoscope reprocessor as part
of flexible endoscope reprocessing can replace manual cleaning. One article found that the
automated washing phase of the endoscope reprocessing system studied was equivalent to
optimal manual cleaning for the makes and models of flexible endoscopes tested(95). As new
technological advances develop and Automated Endoscope Reprocessors (AERs) with a washing
cycle are marketed, there will be the need to assess the cleaning efficacy of these new devices.
Until such studies are completed, cleaning needs to be done manually.

1.4. Disinfection and Sterilization

Sterilization is considered optimal, however, the minimum acceptable standard for reprocessing
endoscopes is high level disinfection (HLD). Currently, most of the available flexible
endoscopes are temperature sensitive and cannot undergo steam sterilization. (Note: there are
some makes of bronchoscopes that can be steam sterilized, but these are not widely used).

37
 If a high level disinfectant is used, it is critical that exposure
time, temperature and concentration of the active ingredient
are consistently achieved and strictly controlled.

1.4.1. Selection of a High Level Disinfectant Product

The characteristics of an ideal liquid chemical (LC) agent used as a high level disinfectant should
include broad antimicrobial spectrum, rapid onset of action, compatibility with delicate
instruments, lack of toxicity for healthcare staff, patients and the environment, no odour, non-
staining, unrestricted disposal, prolonged reuse and shelf life, ease of use, remains active in the
presence of protein and organic material, ability to be monitored for concentration, and relatively
low cost. No currently marketed product satisfies all these criteria. Major disadvantages include
material incompatibility (e.g., peracetic acid, hydrogen peroxide) and human toxicity (e.g.,
glutaraldehyde)(102).
Despite their limitations, LC agents are convenient, relatively fast- acting, and universally used
to reprocess flexible endoscopes and other instruments. When selecting a high level disinfectant
product, infection prevention personnel should assess their institution’s requirements (e.g.,
number of endoscopes processed per day, training, turnaround time required), obtain cost
information, and know provincial and federal regulations regarding safe use and disposal
requirements. It is important that healthcare workers who use any high level disinfectant, be
familiar with and have readily accessible, product/brand-specific Material Safety Data Sheets
(MSDS) for all chemicals used, and keep current with developments in products and practice.
Table 5 lists the currently approved low temperature products/methods for disinfection/
sterilization of flexible endoscopes and comments regarding appropriate use. For detailed
information on advantages and disadvantages of available high level disinfectant products, the
reader is referred to Best Practices for Cleaning, Disinfection and Sterilization In All Health
Care Settings(2;12;102).

1.4.2. Liquid Chemical Agents

The most common method for disinfection/sterilization of flexible endoscopes is the use of
liquid chemical (LC) agents including glutaraldehyde, ortho-phthalaldehyde (OPA), peracetic
acid, and hydrogen peroxide (see Table 5). Glutaraldehyde has exposure threshold limit values
as specified in provincial Occupational Health and Safety (OH&S) regulations and special air-
handling requirements are necessary when this agent is used, due to its propensity to cause
sensitization reactions in some healthcare workers. The correct contact time for the particular
chemical agent used must be adhered to as indicated in Table 5. Glutaraldehyde (either alkaline
or acidic) requires a minimum of 20 minutes contact time at room temperature. Although the
manufacturer recommends 45 minutes contact time at 25°C, current guidelines and expert
opinion confirm that 20 minutes at room temperature (20°C) is adequate provided that thorough
pre-cleaning has been performed prior to exposure to the glutaraldehyde(1;3;38;40;90;103-105). Ortho-
phthalaldehyde (OPA) has the shortest exposure time at 10 minutes at room temperature (min
20°C), or a contact time of 5 minutes if used in AERs at a minimum temperature of 25°C.

38
The information listed in Table 5 is current at the time of publication. Always refer to the
manufacturer's instructions for product and for further details. Ensure that a Drug Identification
Number (DIN), indication that the product is licensed by Health Canada for the Canadian
market, is on the product container.

1.4.3. Low Temperature Gas and Gas Plasma Sterilization

Sterilization must be performed if the endoscope enters the body through an incision, as with
intraoperative enteroscopy(12;14). Low-temperature sterilization (<60 degrees C.) is required for
temperature and moisture-sensitive critical medical devices. All currently developed sterilization
processes have limitations and these must be understood to ensure the proper application of new
sterilization technologies within medical facilities(106).

Regardless of the sterilization method used, scrupulous manual

cleaning must precede sterilization to remove organic debris
and salts(107-111)

Ethylene oxide (ETO) has been the most widely used low-temperature sterilization process. The
compatibility of ETO with a wide range of materials has made it the most suitable process for
the majority of heat and/or moisture-sensitive medical devices, however, there are potential toxic
hazards to staff , patients and the environment, as well as risks associated with handling a
flammable gas(112). The International Agency for Research on Cancer (IARC) has upgraded its
classification for ETO from 2A to a group 1 (known human carcinogen)(113). A properly
designed ventilation system dedicated to removing ethylene oxide, safe workplace practices and
ongoing training can minimize the worker's exposure to the product(114).
Ethylene oxide (ETO) is an acceptable method of sterilizing flexible endoscopes, however, a
lengthy aeration time is required for equipment post-exposure in order to allow desorption of all
residual toxic gas from the endoscope to occur. In addition, additional steps must be taken (e.g.,
application of a venting valve or the removal of the water resistant cap) to ensure proper
perfusion with the gas and to prevent damage due to pressure build-up. There are specific cases
for holding flexible endoscopes during this process (manufacturer’s recommendations should be
followed). Do not place flexible endoscopes in their storage cases when being sterilized using
ETO.
Low-temperature hydrogen peroxide gas plasma sterilization has been used in hospitals
worldwide for over a decade(115). Unlike ETO, hydrogen peroxide is not toxic and does not leave
significant residue on the sterilized instruments. Alfa(107;116) demonstrated difficulty in achieving
sterilization of narrow lumens in the presence of serum and salt with plasma-based sterilization
systems. She also demonstrated that a lumen adaptor/booster, which supplies an additional
source of hydrogen peroxide within the lumen, appears to improve the effectiveness of the
plasma sterilization process. Newer gas plasma sterilization technologies have been found to be
superior to older systems and improve the margin of safety of this sterilization process(109;117-119).

39
When reprocessing an endoscope with a hydrogen peroxide gas plasma sterilization process,
ensure the lumens are made of Teflon® or polyethylene and that the lumens conform to the
dimensions specified by the manufacturer for the specific sterilizer. Ascertain that the endoscope
is made of materials that are compatible with this reprocessing method. Should the lumens or
materials not conform to the manufacturer’s recommendations, consult with the manufacturer of
the endoscope for information on how to properly sterilize the device.

40
 Table 5. High Level Disinfectants/Sterilization Methods Currently Used for Reprocessing Flexible Endoscopes

ACTIVE INGREDIENT CONTACT TIME COMMENTS

High Level Disinfection

2% Glutaraldehyde minimum of 45 minutes at 25ºC is indicated • Aldehydes are protein fixatives, therefore it is critical that medical devices have
by the manufacturers (a minimum of 20 been thoroughly cleaned and rinsed prior to exposing to glutaraldehyde as any
minutes at room temperature (20ºC) is residual protein will be fixed onto the surface by this high level disinfectant.
adequate according to expert opinion and Because of this protein fixing property, aldehydes should not be used for
published guidelines) reprocessing scopes used in patients with suspect, possible, or proven prion
infection.
• Vapours from glutaraldehyde are sensitizing and work areas need to be properly
ventilated to ensure levels are below threshold limit values (TLVs) specified in
Occupational Health & Safety (OH&S) regulations. Use of an AER mitigates this
aspect.
• Recirculation of air in the area where the product is used is prohibited by OH&S
regulations and ventilation must be to the exterior. The product Material Safety
Data Sheet (MSDS) stipulates 10 fresh air exchanges/hour in the area where
product is used.
• Scheduled air quality monitoring is essential to ensure control of glutaraldehyde
vapours.
• Glutaraldehyde is reusable for 14 to 28 days (depending upon formulation).
• Minimal effective concentration (MEC) testing is required.
• Glutaraldehyde has a long history of use and is less expensive/gallon than other
agents.
• Disposal down the drain may be regulated in some areas.

41
 ACTIVE INGREDIENT CONTACT TIME COMMENTS

Ortho-phthalaldehyde (OPA) minimum of 10 minutes at room temperature • OPA is an aldehyde and cross-links proteins similarly to glutaraldehyde, however
(20°C); it is much less active as a fixative compared to glutaraldehyde. Because of this
protein fixing property, it should not be used for reprocessing scopes used in
minimum of 5 minutes at 25°C (when used
patients with suspect, possible, or proven prion infection.
with an AER)
• Fumes may cause sensitization but there are fewer problems with air levels
compared to vapours from glutaraldehyde. The product MSDS stipulate 10 fresh
air changes/hour in the area where product is used.
• No air quality monitoring for vapours is required.
• OPA is reusable for 14 days.
• MEC testing is required.
• Rinsing after exposure to OPA is critical as OPA is hydrophobic and hard to rinse
off flexible endoscopes. Use of AERs facilitates adequate rinsing post-exposure.
• OPA is more costly than some products.
o
7.5% Hydrogen Peroxide 15 to 30 minutes at 21 C (depending upon • Materials compatibility issues have been documented with brass and copper, thus
formulation) the product is not widely used for flexible endoscopes.
(Some 3-4% formulations have also been
validated for high level disinfectant-check • MEC testing is required.
manufacturer’s label claims)
• The product is reusable for 14 days.
o o
0.2% Peracetic Acid 5 minutes at 30 C or 12 minute at 50-56 C • No vapour issues exist (except during accidental spills).
depending on the formulation
• Product can be disposed of down the drain.
• Product causes cosmetic changes to aluminum anodized coating.

Sterilization
Ethylene Oxide (ETO) (100% formulation, or 30 minutes to 1 hour exposure (depending on • 8-12 hours mechanical aeration is required at 50-60°C(120).
carrier gas that is not Freon® based) sterilizer)
• Monitoring of ETO exposure levels for staff is required as per TLV in OH&S
regulations. Federal regulations must be followed(114);(121).
• Recirculation of air in the area where the product is used is prohibited by OH&S
regulations and ventilation must be to the exterior.
• Special ETO approved cases are needed for flexible endoscopes.

42
 ACTIVE INGREDIENT CONTACT TIME COMMENTS

Gas Plasma (vaporized hydrogen peroxide) ~ 50 minutes • Product is safe for the environment, as there are no fumes.
• Limitation due to poor penetration of the gas in long and narrow lumens
• Limitation in material compatibility.

• Only wraps appropriate for use with gas plasma can be used.

Note: Readers are advised to check the Health Canada – Therapeutic Product Directorate (TPD) website for updated licensing information.

43
 1.4.4. Automated Endoscope Reprocessors (AERs)
Automated endoscope reprocessors (AERs) standardize the disinfection process and decrease
personnel exposure to a high level disinfectant and sterilants(122;123). The AER manufacturer is to
provide a list of the flexible endoscopes that have been validated for reprocessing in their
specific AERs, and a list of chemical disinfectants/ sterilants that can be used with the AER(124).
Some AERs use dedicated single-use liquid chemical agents whereas other AERs may
accommodate a range of reusable high level disinfectants. In each case, the AER manufacturer’s
device-specific instructions must be followed and only endoscopes that are compatible with the
AER (as indicated by the endoscope and AER manufacturer) should be reprocessed by these
methods.
If the AER manufacturer recommends that connectors be used for flexible endoscopes
reprocessed in the AER, then the correct connector for the specific endoscope being reprocessed
must be used(124-126). Current AERs will always have disinfection and rinse cycles. In addition
to these basic disinfection and rinse cycles, they may also have one or more of the following
capabilities: leak testing, cleaning cycle, alcohol rinse, and drying cycle.

Regardless of the AER used, manual cleaning (including thorough rinsing) must be
performed prior to placing the flexible endoscope into the AER (even if the AER cleaning
cycle is used)(123;124).

Utilization of the AER cleaning cycle provides an extra margin of safety by providing additional
cleaning, but it does not replace the absolute requirement for thorough manual cleaning.
Also, even if the AER has leak testing capacity, manual leak testing should still be performed
prior to manual cleaning. If an alcohol rinse is not part of the AER cycle, this step needs to be
performed prior to manual forced air-drying when the flexible endoscope is going into storage.
Investigations of infections following bronchoscopy have revealed breaches in the reprocessing
procedure associated with the AER(34;65). Reports have also identified inconsistencies between
the reprocessing instructions provided by the AER manufacturer and the endoscope
manufacturer leading to bronchoscopes being inadequately reprocessed when inappropriate
channel connectors were used(126;127). In Canada, awareness of microbial growth in critical
components of the AER even when recommended AER maintenance had been followed has
further added to the concern over problems with AERs. As a result, the Therapeutic Product
Directorate (formerly the Health Product and Food Branch) of Health Canada has issued
recommendations for selecting an AER(124). The criteria listed in Table 6 are also detailed in
Part V. Recommendations for Endoscopy and Endoscopy Decontamination Equipment, Section
2.0 (f) i-vii of this guideline.

44
Table 6: Selection of an Automatic Endoscope Reprocessor(124)

When purchasing an AER, ensure the following criteria are met:

• the AER is licensed for sale in Canada,
• there are no potential reservoirs of infection - areas in the AER where water or
disinfectant can stagnate,
• the AER can effectively irrigate all channels of any endoscope to be
reprocessed in the AER, ensuring effective contact between the chemical
disinfectant and the channel walls,
• for wash cycles ensure that all wash fluids (water and chemicals) are
completely drained and discarded following each wash cycle ensuring that
there are no potential reservoirs of infection (areas in the AER where water
can stagnate) and reuse of contaminated wash fluid is not possible,
• for the disinfection cycle, ensure that water and chemicals are completely
drained between cycles,
• if the AER uses a single-use disinfectant ensure that the disinfectant is
completely drained and discarded after each cycle,
• if the AER uses a reusable disinfectant, ensure that the minimum effective
concentration (MEC) is monitored daily using test strips available from the
supplier of the disinfectant. Discard the disinfectant in accordance with local
regulations at the end of the disinfectant's specified reuse life (as specified by
the disinfectant supplier) or following a failed MEC test, whichever comes
first,
• the cycle length and temperature can be adjusted to ensure high-level
disinfection or sterilization based on the disinfectant/sterilant used,
• the cycle length can be adjusted to ensure adequate rinsing based on the type
of endoscope being reprocessed,
• the manufacturer of the AER identifies by brand and model each endoscope
that may be effectively reprocessed in the AER and the limitations of the AER
in reprocessing certain models of endoscopes and accessories (e.g.: the lumen
diameter of the elevator wire channel in a duodenoscope may not permit
adequate fluid flow to effectively reprocess this are of the endoscope).

1.4.5. Reprocessing Endoscopic Accessories

Because of their complex nature, attention and adherence to a validated protocol is critical for
reprocessing endoscope accessories. Accessories such as biopsy forceps, papillotomes,
sphincterotomes and cytology brushes may be available as single-use (disposable) or reusable
instruments. All reusable endoscopic accessories that breach mucosal barriers are considered
critical and require cleaning with an ultrasonic cleaner followed by sterilization between
patients(4;12;14;47). Manufacturer’s guidelines for the care and usage of reusable products must be
strictly followed(11;128).
It is important that each institution be fully aware of the issues involved in accessory device
selection. For instance, if reusable accessory devices are used, the institution must have
appropriate cleaning equipment (e.g., ultrasonic cleaner) to accommodate proper reprocessing.

45
Contaminated or damaged medical devices pose a potential source for cross-contamination,
infection and injury to patients and personnel. In an outbreak of 8 cases of Salmonella newport
infection among patients undergoing colonoscopy, the epidemic strain was not recovered from
the four colonoscopes used during the outbreak but was recovered from the spiral-wound spring
of a pair of biopsy forceps, which are difficult to clean mechanically(58). Presently the only
method that effectively penetrates the metal coils of the spring is steam under pressure(4;101).
Although still controversial, the reuse of critical and semi-critical single-use devices (SUDs) has
been commonplace in many institutions, and undertaken primarily for economic reasons(129).
The results of a recent survey show that Canadian hospital practices have not changed much in
the last decade and that a minority of hospitals reprocess SUDs(130). In the US, guidelines
stipulate that the reprocessing of single-use devices must conform to the same standard as the
manufacturer provides. While there are some third party companies that provide this service, it
must be rigorous and controlled. Currently there are no licensed third party reprocessors in
Canada(2;131).
In circumstances where the manufacturer does not approve of reuse, the facility will be legally
responsible in establishing when and under what conditions the reuse of medical devices presents
no increased risk to patients and that a reasonable standard of care was maintained during reuse
of the device. All institutions that choose to reuse single-use accessory devices need to validate
the sterility and integrity of the reprocessed devices, and have in place detailed protocols that
include mechanisms for ongoing evaluation and quality assurance monitoring. This includes the
training and retraining of staff, as well as policies and standards to determine the maximum
number of uses for the device and to track their usages(132-134). In general, the reuse of single use
medical devices is discouraged.

Table 7 - Health Canada Recommendations(124)

I. Reusable Medical Devices

• Healthcare facilities and healthcare providers should review instructions provided by the
manufacturer prior to the purchase of reusable medical devices to ensure that the device can
be adequately reprocessed with available equipment.
• Healthcare facilities and healthcare providers should require that manufacturers include
complete instructions for use, disassembly, cleaning, reassembly and sterilization with all
reusable devices, and that they provide appropriate training to users where such training is
essential to the safe use of the device.
• Healthcare facilities and healthcare providers should establish procedures and provide
training for staff to ensure that reusable devices are, cleaned, and sterilized according to the
manufacturer’s instructions. These instructions should be filed so that they can be easily
retrieved and consulted by users.
• Healthcare facilities and healthcare providers should validate and regularly review their
sterilization procedures and ensure that they are being followed.

46
• Healthcare facilities and healthcare providers should report to Health Canada any cases in
which the manufacturer does not provide adequate instructions for use, cleaning and
sterilization of a reusable device.
II. Single-Use Medical Devices
• Health Canada is concerned that reusing single-use devices may be hazardous to patients.
Health Canada is addressing this issue in consultation with the Provinces, Territories, and
stakeholders.

1.4.6. Valves and Water Bottles

Outbreaks involving removable parts such as suction valves(59) have been reported. Following
each endoscopic procedure, valves must be removed from the endoscope, manually cleaned, and
high level disinfected or sterilized according to the manufacturer’s instructions. It is imperative
that all crevices be stringently cleaned so as to be free of debris. The use of an ultrasonic cleaner
to enhance soil removal is recommended. Adequate rinsing must be done after sonication to
remove any loosened soil. Water bottles and their connecting tubing should be sterilized or, at a
minimum, high level disinfected at least daily and sterile water only should be used to fill the
bottles(1;33;85;135).

Note: Each ERCP procedure requires a fresh sterile bottle filled with sterile water(1;135).

2. Sheathed Endoscopes
One approach that has been proposed to avoid the need for an elaborate reprocessing procedure
is to use a sheathed endoscope. The sheathed endoscope includes a reusable endoscope without
channels, and a sterile sheath set comprising a single disposable unit: a sheath; air, water, and
suction channels; a distal window; and a cover for the endoscope's control body. All
contaminated surfaces, including the channels, are then discarded, thereby eliminating any
concern for cross-transmission of infectious agents from the previous patient(136). There are few
studies concerning the use of sheathed instruments for upper and lower endoscopy. In one
prospective study(137), investigators found that the reprocessing turn-around time of the sheathed
instrument was significantly faster (i.e., 9.6 minutes versus 47 minutes) than for a conventional
gastroscope. Other studies(138;139) have reported similar results with reduced instrument turn-
around time, but there are concerns about the functional ability of the sheathed endoscopes as
well as the cost of the sheath compared to the cost of reprocessing the endoscope(140).

3. Storage of Flexible Endoscopes

Flexible endoscopes should be stored in a designated cabinet with a door, in a manner that
prevents recontamination or damage(141).

47
Storage cabinets should meet the following criteria:
• made of material that can be disinfected weekly with an approved low-level disinfectant,
• ventilated when doors are closed,
• not situated in a procedure room, reprocessing area, or a high traffic area,
• easily accessible to ensure scopes can be placed inside without damage and without putting
the HCW at risk (e.g., HCW must reach a high shelf where endoscope is stored),
• should accommodate a sufficient number of endoscope to support the patient volume,
• designed to allow scopes to be stored in the vertical uncoiled position to facilitate drying.

There are storage cabinets available with connections that provide airflow through the endoscope
channels, thereby ensuring thorough drying of the channels(142). Such special storage cabinets
are not necessary if adequate manual drying is achieved prior to storage. If a flexible endoscope
is to be stored without being used for more than a week, it must be reprocessed prior to use(143-
146)
.
It is critical that the valves are stored separately from the endoscope. They may be placed in a
mesh bag and hung on the scope but should not be positioned in the valve port of the endoscope.
Storage of endoscopes with the valves in place can trap moisture within the channels and lead to
microbial growth and biofilm formation within the channels(141).
The carrying case used to transport clean and reprocessed endoscopes outside of the healthcare
environment should not be used to store an endoscope or to transport the instrument within the
healthcare facility. An endoscope placed in its transport case will require reprocessing before
use on a patient. Should the transport case become contaminated, contact the manufacturer for
further instructions. In some instances, the transport case may need to be discarded(85;147).

4. Quality Management
Proper reprocessing of flexible endoscopes is mandatory to ensure safety of patients undergoing
pulmonary and GI endoscopy. A quality management program should include the following
elements(4;6;11;101;148).

Staff training
• The assigned staff must have received sufficient training to safely and properly perform the
reprocessing process. The training should be ongoing and includes hands on training with
the specific endoscopes used in the facility and should be documented by the supervising
educator.
48
• The introduction of new equipments should be preceded by adequate training of the staff. An
annual recertification program should be considered.
• The use of written protocols with frequent reminders to staff to not deviate from written
instructions.
Administrative
• Equipment monitoring including visual inspection to identify conditions that may affect the
cleaning or disinfecting process.
• Maintain a record of each endoscopic procedure, including but not limited to: the type of
procedure with date & time, model and serial number of the endoscope used, patient
information, staff involved with the procedure, information on the reprocessing method (e.g.,
AER serial number or identifier, chemical used, staff performing the reprocessing). This
information will facilitate the ability to retrospectively link the scope used for each patient
procedure.
• Annual audits of the reprocessing processes and infection prevention and control practices.
• A preventative maintenance program should be in place for all medical devices (i.e.,
endoscopes, AER, leak tester).
• A surveillance system capable of detecting clusters of infections or pseudo-infections
associated with endoscopic procedures.
• Inform infection prevention and control personnel of any suspected or identified infection.
• Ensure infection prevention and control personnel are consulted when reviewing,
changing or updating the reprocessing procedure or policy.

4.1. Staff Training

The reprocessing of flexible endoscopes has a narrow safety margin due to the complexity of the
devices and the processes used. Deviation from the manufacturer’s recommendations for
reprocessing could potentially lead to residual microorganisms being left on the device and thus
increase the risk of infection(95). The reprocessing of flexible scopes, like all human endeavours,
is prone to error as it is a multi-step process relying on both humans and automated or manual
cleaning equipment. Inexperienced or untrained staff handling flexible endoscopes during
reprocessing increases the likelihood of errors. A major element of quality management is
ensuring the provision of device-specific training for endoscopy staff and ongoing competency
testing to ensure compliance with protocols.
Competent personnel that maintain consistent excellence in practice are crucial to proper
cleaning and disinfection of endoscopes(2-4;6;7;9;11;16;45;85;91;149).
Infection Prevention and Control education is a critical part of the orientation and continuing
education for all personnel, including physicians, nurses, and technical staff who work in the
endoscopy setting(6;9). The orientation and continuing education program should include, but not
be limited to, the following topics:

49
• Mechanisms of disease transmission,
• Routine Practices and Additional Precautions,
• The appropriate use of personal protective equipment,
• Occupational health and safety regulations,
• Reprocessing procedures for flexible endoscopes and accessories,
• Safe work practices,
• Safe handling of chemicals used in reprocessing,
• Safe waste management.
See Appendix G for sample training protocol.

4.2. Preventative Maintenance and Repair

Periodic assessments of the endoscopes by qualified personnel can reduce both patient risk and
repair costs. Manufacturers will provide trained technical personnel for such assessments and in-
house service. Repairs should always meet or exceed the manufacturer’s original specifications
and Original Equipment Manufacturer (OEM) parts should be used. Detecting the need for
minor repairs before further damage occurs can prevent use of a substandard endoscope on a
patient, and may also prevent unnecessary major repairs and cost.
During the manual cleaning process, trained personnel should inspect devices for functionality
and damage(4;11). If an endoscope requires repairs, it is important to ensure proper disinfection; if
disinfection is not possible, then handling precautions as specified by the service vendor must be
followed when shipping a contaminated endoscope, and according to provincial and federal
guidelines for the transportation of dangerous goods(11). When an endoscope requires repairs by
a party other than the original manufacturer (i.e., third party repairs), the provider of the service
should provide information that the new or repaired product meets or exceeds the specifications
of the original product (e.g., if the suction channel is changed or repaired, the material used
should be physically compatible with the high level disinfectant used).

Repairs must be performed by a party knowledgeable on the various materials used for
repairs and on the mechanical complexity of the flexible endoscope being repaired.

4.3. Monitoring Microbial Bioburden in Flexible Endoscope Channels

There are two potential problems that may arise during the reprocessing of flexible endoscopes:
i) persistence of organic material if cleaning is inadequate, and ii) presence of residual
microorganisms if high-level disinfection /sterilization are suboptimal or if endoscopes are not
dried before storage. The role of ongoing environmental endoscopic surveillance cultures to
monitor the effectiveness of routine cleaning and disinfection techniques remains controversial.
Australian(10), French(150), and the European Society of Gastrointestinal Endoscopy (ESGE) and
the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA)(151)
guidelines advocate routine culturing of flexible endoscopes and AER for specific pathogens.
50
North American guidelines, for the most part, do not recommend routine monitoring of
endoscope channels unless infection transmission, an outbreak, or a reprocessing error has been
identified(3;4). Routine bioburden monitoring of flexible endoscope channels may be useful as a
“process monitor” by providing a valuable quality assurance tool to help identify previously
unknown problems with the reprocessing process(135;136;152-154). The results of this monitoring
could be used to reinforce staff compliance with proper reprocessing techniques or identify a
need to revise reprocessing policies and procedures. Bioburden monitoring should not be used to
identify a specific endoscope in need of better reprocessing before use. Whether patient
disclosure is required post-endoscopy if deficiencies in reprocessing are identified through the
process monitor is controversial. Appendix D provides an outline of how bioburden testing
could be performed as part of an outbreak investigation.

5. Healthcare Worker Protection During Endoscopy/Bronchoscopy and

During Equipment Reprocessing

5.1. Hazards During Endoscopy

Endoscopy and bronchoscopy procedures can put both the patient and the healthcare worker
(HCW) performing the procedure at risk for infection. Although transmission of a blood borne
pathogen from patient to HCW during endoscopy has not been documented, it is possible. A
needlestick or “sharp” injury involving an infected patient represents the greatest risk of
transmission of a blood borne pathogen to HCWs. The probability of transmission from a
needlestick/sharp injury has been estimated at up to 30% for HBV, 4% for HCV, and 0.25% for
HIV(19;155). The likelihood of percutaneous exposure to blood borne pathogens relates primarily
to injury with sharp, contaminated endoscopic accessories (e.g., snares, biopsy forceps).
However, the possibility of mucous membrane exposure to contaminated secretions is real if
personal protective equipment (PPE) is not worn(13;46). It is essential that all HCWs working in
the endoscopy unit follow Routine Practices to minimize the risk of infection.
Of equal concern is the risk for transmission of tuberculosis (TB) from infected patients who are
undergoing bronchoscopy(72). Infection prevention and control precautions stipulate staff use of
N95 respirators when patients with a potential respiratory infection are undergoing
bronchoscopy.

5.2. Hazards During Reprocessing

Reprocessing procedures present the potential risk of biological (e.g., infectious agents) and
chemical (e.g., high level disinfectant) exposures. HCW infection can occur during improper
handling of patient contaminated instruments, such as the endoscope or accessories after the
procedure. Prior to undertaking any cleaning of a flexible endoscope, personnel should put on
the appropriate PPE. Reprocessing staff need to recognize that even after the flexible endoscope
has been manually cleaned, there may still be viable infectious microorganisms in or on the
endoscope (the cleaning process does not disinfect the endoscope) and appropriate use of PPE is
still necessary for handling the endoscope after cleaning.
Cleaning and disinfecting endoscopes involves the use of chemicals that can emit toxic fumes
and exacerbate allergies. To avoid danger to staff, patients, and the environment, prudent use as

51
well as established safety precautions are required. Refer to the product label of each product or
the MSDS associated with each product for appropriate handling.

5.3. Infection Prevention and Control Practices and Precautions

The most important ways to prevent acquiring an infection are to perform good hand hygiene
and wear the appropriate PPE. In addition, proper removal of PPE after the procedure is
essential, as the PPE itself can be a source of infection. All personnel involved in the endoscopic
procedure and/or reprocessing the endoscope after use require education in the basic principles
of ‘Routine Practices’(13) and ‘Hand Hygiene’(12). Hand hygiene should be performed before and
after every contact with a patient and his/her surroundings(12;156). Gloves and a fluid resistant
gown should be worn during an endoscopic procedure and while cleaning endoscopes. Gowns
should be changed between patient procedures, after cleaning instruments, and/ or when they are
dirty(157). Although rare, there have been case reports of HCV transmission from a blood splash
to the conjunctiva of HCWs(158;159), as has a case of bacterial conjunctivitis following a splash
during colonoscopy(73). Therefore, facial protection (i.e., mask and eye protection/ face shield)
should be worn to protect the mucous membranes of the eyes, nose and mouth during all
endoscopic procedures and while reprocessing instruments. Eyeglasses are not sufficient to
protect from splashes. For endoscopy procedures, in general, a surgical/procedure mask will
suffice. If an infection is suspected a NIOSH certified N95 respirator should be worn during
bronchoscopy(160-163). PPE should not be worn outside the room in which the procedure takes
place or outside the room in which the instruments are cleaned.

5.4. Occupational Health and Safety Considerations

Healthcare workers working in environments where endoscopes are handled should receive all
vaccines as recommended by the National Advisory Committee on Immunization(164) including
the hepatitis B vaccine. HCWs should also have regular tuberculin skin tests (TST), as per
Health Canada: Guidelines for preventing the transmission of tuberculosis in Canadian health
care facilities and other institutional settings(165). The frequency of TST will depend on the
burden of patients with TB actually seen in the clinic (e.g., annually or every 6 months for high
risk facilities)(165). In the event of an exposure to a patient with infectious TB, the hospital’s
protocol for post exposure management should be followed. Similarly, if there is a percutaneous
or mucous membrane exposure to blood or body fluids during the procedure, follow-up through
Occupational Health and Safety is required.
Exposure to glutaraldehyde can cause headaches, conjunctivitis, dermatitis, asthma-like
responses and nasal irritation(21). This can be minimized with appropriate point-of-use
ventilation in accordance with the MSDS for the product used(11). Less toxic high level
disinfectants (e.g., 0.55% ortho-phthalaldehyde) are now available, but no option is ideal(166).
While cleaning endoscopes, to protect against contact with chemicals that can cause caustic
injuries, personnel should wear gloves, facial protection (i.e., mask and eye protection/face
shield) to protect the eyes, mucous membranes and face from splashes, and moisture-resistant
gowns or aprons that protect the body(157). All chemicals must be stored and handled
appropriately and all personnel who handle chemicals need to be aware of the hazards associated
with the materials and how to manage spills. Refer to the product label of each product, or the
MSDS associated with each product for appropriate handling.

52
 5.5. Environmental Controls
Certain microorganisms are transmissible by the airborne route (e.g., TB), and thus
environmental controls are required. A negative pressure room is required for all bronchoscopy
procedures and in the area where the patient is recovering from the procedure(165;167). A
minimum total air exchange rate of 12 per hour is recommended for newly constructed
bronchoscopy suites with 6 exchanges per hour for existing facilities. The direction of air should
be inward (negative pressure) and the air should be exhausted to the outdoors through a
dedicated system or HEPA filtered(9;167-169). The endoscopic instrument reprocessing room
should be under negative pressure and requires an air exchange rate of, at minimum, 8 per hour
to protect personnel from toxic vapours generated by cleaning or disinfecting agents, and
covered containers should be used for additional control of vapours(167;170).
Work areas need to be properly ventilated to ensure product levels are below threshold limit
values (TLVs) specified in provincial OH&S regulations. Recirculation of air in the area where
the product is used is prohibited by OH&S regulation and ventilation must be to the exterior. Use
of an AER helps to reduce vapour concentration and the risk from splashes.
Ethylene oxide (ETO) is a designated substance under the Canadian Environmental Protection
Act. Healthcare facilities that use 10 kg. or more of ETO per year for sterilization must comply
with Environment Canada: Guidelines for the Reduction of Ethylene Oxide Releases from
Sterilization Applications(121) and Canadian Standards Association Z314.9-01: Installation,
Ventilation, and Safe Use of Ethylene Oxide Sterilizers in Health Care Facilities(114).

6. Endoscopy Unit Design

The design of an endoscopy unit is important to facilitate proper infection prevention and control
and occupational health and safety. Major considerations in design and use of space for patient
procedures, equipment reprocessing and storage include: i) patient volume, ii) traffic flow, and
iii) types of endoscopic procedures performed(4). The main objective is to create an efficient
flow of patients and personnel through the unit, from reception to procedure and then to
recovery, while maintaining a distinct separation between patient care areas and contaminated
space and equipment. Providing comfortable working conditions for clinical staff, as well as
support personnel, will promote an environment where proper procedures are routinely
exercised. An ideal endoscopy unit would permit a one-way or circular flow for patients and
endoscopes.
In procedure rooms, the workflow should be from clean to dirty. A dedicated clean area should
be provided for charting, dictation and supplies. A separate soiled holding area must be provided
for pre-cleaning of scopes and handling of contaminated instruments. The procedure room
should have a separate dedicated hand washing sink with hands-free controls.
An appropriate airborne precautions environment should be available for patients with confirmed
or suspected infectious airborne diseases if they cannot be immediately transported to an
appropriately ventilated room(13;165).
In designing an endoscopy unit, consideration should be given to providing patients with private
bathroom and change room. A staff lounge should be made available as eating, drinking,
personal hygiene (e.g., cosmetic application, contact lenses) activities should be prohibited from
all patient care areas and the reprocessing room(4;171).
53
Instrument reprocessing space should be physically separate from patient procedure rooms,
maintained as a restricted access area, and enable personnel to respect the one-way work-
flow(11;167). Reprocessing functions can be broken down into 3 general areas: cleaning,
decontamination, and storage. The workflow should be unidirectional from the contaminated or
‘dirty’ area to the clean assembly area and then to storage. Adequate space should be provided
for each function with dedicated storage space in a separate room(167). Reprocessing areas should
have dedicated plumbing and drains(11), and if AERs are used, the area should be designed with
adequate space and utility connections specific to the machine being used(4;167). Adequate space
for storage of chemical disinfectants should be considered near the AER. Other considerations
for an endoscope reprocessing area include monolithic or joint free flooring(167) and stainless
steel counters. Sinks should have rounded edges and enough depth to facilitate complete
immersion of the endoscope. The size of the sink should be adequate to ensure the endoscope
can be positioned without tight coiling as this could damage the fiberoptic bundles. Any other
design features that promote easy cleanup are desirable. Hands-free doors and sinks will
improve workflow and reduce risk of cross contamination. Separate, dedicated hand washing
sinks must be at each entrance or exit.
Appropriate ventilation (see Section 5.5) must be provided to remove toxic vapours of
disinfection chemicals and to handle any aerosolized particles or microbes. The manual cleaning
and disinfection space should be under negative pressure in relation to the adjoining rooms,
whereas the endoscope storage space should be under positive pressure(170). Ventilation in the
storage area should be adequate to ensure dry storage of clean endoscopes.

7. Surveillance and Outbreak Investigation and Management

Few healthcare settings have routine post-procedure surveillance programs in place to monitor
the incidence of endoscopy-associated infections. Many endoscopies are now carried out in
outpatient clinics and follow-up of patients in the community is difficult. In addition, some
infections, such as hepatitis B and tuberculosis, have long incubation periods, and thus clinical
infection developing later may not be linked to an earlier endoscopy. It has been suggested that
infection surveillance programs be implemented, at least periodically, for high risk procedures
such as Endoscopic Retrograde Cholangiopancreatography (ERCP)(45).
An outbreak is defined as an increase in the rate of infection or disease above the usual. This
requires that ongoing surveillance for potential complications be in place so that the background
rate is known or can be calculated, or alternatively that a retrospective review could be
performed to obtain baseline data. There have been numerous reported outbreaks of infection
related to endoscopic procedures (See Table 1) as well as transmission of microorganisms
without disease related to contaminated endoscopes (See Table 2).
Any occurrence of infection after an endoscopy procedure should be reviewed since it might be a
sentinel event that signals the occurrence of an outbreak. If an outbreak is suspected, an
investigation should be initiated(4;172). Appendix H outlines steps to be taken during an outbreak
investigation. Many of these steps may be performed concurrently.

8. Investigation of a Reprocessing Problem

Potential exposure events due to breaches of disinfection and sterilization guidelines(57;173), and
failures in the disinfection or sterilization processes(25) are not uncommon in healthcare settings.
54
The purpose of investigating a potential reprocessing problem is to discover the factor(s) that led
to the potential exposure and to protect patients from adverse events, and not to assign blame to a
particular person or persons.
Any investigation should be undertaken using a standardized approach. Rutala et al.(174) have
described a process for exposure investigation after potential failure of a disinfection/sterilization
procedure. Table 8 outlines steps to be taken to investigate a reprocessing problem. Every
situation is unique, therefore steps taken in the investigation should be adapted to the specific
situation. In addition, the American Society for Gastrointestinal Endoscopy (ASGE) has recently
published guidelines for patient notification and follow-up when a significant breach in
reprocessing has been discovered(175).

55
Table 8. Investigation of a Reprocessing Problem

1. Confirm disinfection or sterilization reprocessing failure (e.g., review time and date of possible failure,
sterilization method used, process parameters, and physical, chemical, biological indicators).

2. Impound any improperly disinfected/sterilized items.

3. Do not use the questionable disinfection/sterilization unit (e.g., sterilizer, AER) until proper functioning can
be assured.

4. Inform key personnel (e.g., medical and nursing director of involved unit, risk management).

5. Conduct a thorough evaluation of the cause of the disinfection/sterilization failure (e.g., review exact
circumstances of failure: dates and results of process measures, physical, chemical, biological indicators).

6. Prepare a line listing of potentially exposed patients (e.g., name, identification number), date of exposure,
contaminated device used, underlying risk factors for infection, development of any healthcare-associated
infections, or other adverse events.

7. Assess whether disinfection/sterilization failure increases patient risk for infection.

8. Inform expanded list of personnel of the reprocessing issue (e.g., administration, public relations, legal
department).

9. Develop a hypothesis for the disinfection/sterilization failure and initiate corrective action.

10. Develop a method to assess potential adverse patient events (e.g., laboratory tests for source patients and
exposed persons to blood borne pathogens).

11. Consider notification of provincial and federal authorities.

12. Consider patient notification.

13. Develop long term follow-up plan (e.g., long-term surveillance, changes in current policies and
procedures).

14. Prepare after action report.

Adapted from Rutala(174)

56
PART V. RECOMMENDATIONS FOR REPROCESSING FLEXIBLE
ENDOSCOPES

1. Administrative Recommendations

1.1. Policies and Procedures

a. All healthcare settings where endoscopies are performed should have detailed written
policies and procedures for the cleaning, reprocessing, and handling of flexible
endoscopes that are based on current recognized standards and recommendations.
Policies and procedures should include responsibilities of management and staff and the
qualification, education and training of personnel involved in
reprocessing(1;2;6;11;12;16;91;128).
B II

b. All healthcare settings in which endoscopies are performed should have ongoing access
to infection prevention and control expertise(176-178).
B II

c. All healthcare facilities in which endoscopies are performed should have ongoing access
to and collaboration with an Occupational Health and Safety Program(11).
C II

d. All healthcare facilities where endoscopy is performed should have sufficient resources
to support training and education programs for personnel assigned to reprocess
endoscopes and accessories(6;9;11).
B II

e. Policies and procedures for cleaning and reprocessing endoscopes, endoscope

accessories, and related equipment should be reviewed at least annually, revised as
necessary and readily available in the practice setting. Procedures/modifications should
be documented and reviewed by the facility or organization’s Infection Prevention and
Control Committee, infection prevention and control personnel or other individual(s)
responsible for infection prevention and control in the setting(1;6;11;91).
C II
f. A procedure should be established for the recall of improperly reprocessed equipment
(e.g., incorrect reprocessing method was used on equipment). The recall procedure
should include assessment of patient risk, and a procedure for subsequent notification of
patients, other facilities, and /or regulatory bodies if indicated(2;12).
C II

57
 g. Healthcare settings where endoscopy is performed should have written policies regarding
the use of single-use medical/equipment/devices(2;4;67;130;131;179).
B II

h. The bronchoscopist is responsible for notifying those involved in the endoscopic

procedure as well as those involved in equipment reprocessing as to whether a patient
undergoing bronchoscopy may have tuberculosis.
C II

2. Recommendations for Endoscopy and Endoscopy Decontamination

Equipment
a. Medical equipment/devices that cannot be cleaned and reprocessed according to the
recommended standards should not be purchased(2).
BI

b. All medical equipment/devices intended for use on a patient that are being considered for
purchase should be assessed by infection prevention and control personnel and should
meet established quality reprocessing parameters(2;11). The manufacturer must supply the
following:
i) Information about the design of the equipment/device and clearly indicate
which parts need to be disassembled for reprocessing,
ii) Manuals/directions for use,
iii) Device-specific recommendations for cleaning and reprocessing of
equipment/device,
iv) Education for staff on use, cleaning and the correct reprocessing of the
equipment/device,
v) Recommendations for auditing the recommended process.
B II

c. The manufacturer’s recommendations regarding the installation, care, use, and

maintenance of decontamination equipment should be followed including establishment
of a preventive maintenance schedule. This includes but is not limited to cleaning,
lubrication, checking for leaks, the changing of filters, and verification of settings and
calibrations.
BI

d. Qualified personnel only should perform equipment maintenance and repairs.

C II

58
e. Original Equipment Manufacturer (OEM) parts should be used to repair
equipment(11;34;36).
C II

f. Proper planning and assessment is necessary for the selection and purchase of automatic
endoscope reprocessors (AERs) used to reprocess endoscopes and accessories(124).
i) The AER must be licensed for sale in Canada(124).
ii) The manufacturer of the AER must identify by brand and model each
endoscope that may be effectively reprocessed in the AER and the limitations
of the AER in processing certain models of endoscopes and
accessories(3;124;125).
B II

iii) The reprocessing instructions provided by the endoscope manufacturer and

the AER manufacturer’s instructions should be compared and any conflicting
recommendations should be resolved prior to first reprocessing(3;85;125).
BI

iv) The AER should effectively irrigate all channels of the endoscope. All
channel connectors should be attached according to the AER manufacturer’s
instructions to ensure exposure of all internal surfaces with the high-level
disinfectant/chemical sterilant(3;85;124;126;127).
BI

v) The AER should have no potential reservoirs for microbial growth, i.e., areas
in the AER where water or disinfectant can stagnate. For wash cycles, ensure
that all wash fluids (water and chemicals) are completely drained and
discarded following each cycle(6;124;180).
BI

vi) If the AER uses a single-use disinfectant, the disinfectant should be

completely drained between cycles
C II

vii) If the AER uses a reusable disinfectant, the MEC should be monitored daily
using test strips available from the supplier of the disinfectant(6;16).
B II

59
 g. If an AER cycle is interrupted, high-level disinfection or sterilization cannot be ensured
and the process should immediately be repeated(3;6).
C II

h. Because design flaws have compromised the effectiveness of AERs, infection prevention
and control personnel (or other appropriate personnel) affiliated with the facility should
routinely review Health Canada’s advisories, warnings and recalls about marketed health
products, Emergency Care Research Institute (ECRI) reports, manufacturer alerts, and the
scientific literature for reports of AER deficiencies that may lead to infection(3;34;127;181).
C II

i. If an automatic endoscope reprocessor manufacturer identifies a defect that may impact

on effectiveness of the disinfection/sterilization process, it has an obligation to provide
information to the user detailing the likely impact on disinfection/sterilization.
C II

j. If an endoscope requires repairs, proper disinfection should be performed prior to repair,

or, if disinfection is not possible, then handling precautions as specified by the service
vendor/equipment manufacturer should be followed when shipping a contaminated
endoscope. Preparation and shipping of the endoscope should conform to the applicable
jurisdictional requirements for the transportation of dangerous goods(1;11).
C II

3. Recommendations for Reprocessing Endoscopes and Accessories

3.1. Preparing the Endoscope for Cleaning

a. Immediately after removal from the patient, the exterior surface of the endoscope should
be wiped down with a soft lint-free cloth or endoscope sponge soaked in a freshly
prepared enzymatic detergent solution(1;6;11;101;125).
C II

b. The biopsy/suction and air/water channels should be flushed with an enzymatic detergent
solution. For endoscopes with an elevator wire, manual flushing of this channel with an
enzymatic detergent followed by rinsing is required(1;11;101;125).
B II

c. The endoscope should be transported to the reprocessing area in an enclosed container.

Do not transport contaminated and clean endoscopes in the same container at the same
time(6;11;101).
C II

60
3.2. Leak Testing
a. Pressure/leak testing should be performed according to manufacturer’s instructions after
each use and prior to immersion of the endoscope in the reprocessing solution. Remove
from clinical use any instrument that fails the leak test and have it repaired(1;3;4;6;11;60;85).
C II

3.3. Manual Mechanical Cleaning in the Reprocessing Area

a. Non-immersible endoscopes should not be used(3;4;8;11;16;85).
C II

b. The endoscope and its disassembled components (e.g., suction valves) should be
completely immersed in a freshly prepared enzymatic detergent cleaner(1;3;6;11;15;59;85;182).
C II

c. The entire endoscope, including valves, channels, connectors and all detachable parts
should be meticulously cleaned with an enzymatic detergent compatible with the
endoscope, according to the manufacturer’s
instructions(1;3;5;6;9;11;12;15;43;54;85;90;100;153;183;184).
BI

d. All accessible channels should be flushed and brushed to remove all organic (e.g., blood
or tissue) and other residues. Repeatedly actuate the valves during cleaning to facilitate
access to each surface(1;3;5;6;9;11;28;44;47;85;90;91;100;127;185).
BI

e. Cleaning brushes appropriate to the size of the endoscope channel or port should be used
(i.e., bristle should contact surfaces). Disposable cleaning items are preferred. Reusable
cleaning items should be thoroughly cleaned, inspected for damage and subjected to, at a
minimum, high-level disinfection after each use. Cleaning items should be discarded if
worn or damaged(3;6;9;11;85;90;186).
C II

f. The external surfaces of the endoscope and accessories should be cleaned using a soft,
lint- free cloth, sponge or brushes. Use of a soft bristle toothbrush to clean the lens end is
acceptable(6;11;101).
C II

61
g. Enzymatic detergents should be discarded after each use as these products are not
microbicidal and will not retard microbial growth(3;6;9;11;85;90).
B II

h. The endoscope and all the channels should be rinsed thoroughly with copious amounts of
tap water (minimum of three times the lumen volume) to remove residual enzymatic
detergent. To decrease the possibility of diluting the disinfectant solution, excess water
from the rinse should be removed from the channels by purging with forced
air(1;6;11;12;93;101).
C II

3.4. Sterilization and High Level Disinfection

a. Flexible gastrointestinal endoscopes and bronchoscopes and accessories that come in
contact with mucous membranes are classified as semi-critical items and should receive,
at a minimum, high-level disinfection after each use(1;3;5;7;9;11;12;21;85;90;187).
BI
b. Endoscope accessories that penetrate mucosal barriers (e.g., biopsy forceps or other
cutting instruments) are considered critical items and should be sterile before
use(1;3;11;12;47;58;85;181;187-189). See Section 3.5 Recommendations for Accessories.
B II

c. A Health Canada approved (possesses a drug identification number (DIN)) sterilant or

high level disinfectant should be used for sterilization or high-level disinfection(1;11;12).

d. For cleaning, disinfection and sterilization, only products that are confirmed by the
manufacturer to be compatible with the endoscope and accessories should be used(3-
5;9;11;12;85)
.
C II

e. Formulations containing glutaraldehyde, glutaraldehyde with phenol/phenate, ortho-

phthalaldehyde, hydrogen peroxide, peracetic acid and both hydrogen peroxide and
peracetic acid can be used to achieve high level disinfection if the products are used as
directed (e.g., proper concentration), and objects are properly cleaned, disinfected, rinsed
and dried Refer to Table 5 for specific product recommendations for achieving high level
disinfection and sterilization(1;3;15;43;85;102;118;190-193).
BI

62
f. If manually reprocessed, the endoscope should be completely immersed in the high level
disinfectant/sterilant and all channels should be filled with high level disinfectant. Non-
immersible endoscopes should be phased out(1;3;6;11;15;16;28;85;90;126;127).
C II

g. Endoscopes should not soak overnight. If cleaning and disinfection/sterilization cannot be

performed immediately, soak the endoscope in enzymatic detergent until final
reprocessing can be carried out. Consult the manufacturer’s instructions for delayed
reprocessing(11;101).
C II

h. The exposure time and temperature for disinfecting semi-critical patient care equipment
varies among high level disinfectants. The label claim for high level disinfection should
be followed unless several well-designed experimental scientific studies, endorsed by
infection prevention and control, and/or regulators, and/or guidelines committees,
demonstrate an alternative exposure time is effective for disinfecting semi-critical
items(1;6;7;9;16;100;105;191).
BI
i. If an automatic endoscope reprocessor (AER) is used, the endoscope and endoscope
components should be placed in the reprocessor and all channel connectors should be
attached to the AER according to the AER and endoscope manufacturer’s instructions to
ensure exposure of all internal surfaces to the high-level disinfectant/sterilant. NB: See
Recommendations Section 2. (f) for further AER recommendations(3;4;6;11;85;124;126;127).
BI

j. If an automatic endoscope reprocessor (AER) cycle is interrupted, high-level disinfection

or sterilization cannot be assured and the cycle should be repeated(3;6).
C II

k. After high-level disinfection, the endoscope should be rinsed and all channels flushed to
remove the disinfectant/sterilant. The use of sterile or bacteria-free water is preferred but
tap water can be used. If tap water is used, a subsequent 70-90% alcohol rinse is critical
between each patient use. Discard the rinse water after each use/
cycle(3;5;9;11;15;32;36;66;85;93;100;194-197). NB: If a final alcohol rinse is not included in an
automatic endoscope reprocessor, this step should be done manually followed by
forced air-drying prior to storage(37;181).
B II

63
l. Prior to storage, flush the channels with 70%-90% ethyl or isopropyl alcohol(11;37;39).
B II

m. After flushing all channels with alcohol, the channels should be dried using forced
‘medical grade’ air.(1;3;4;9;11;12;15;29;85;93;198;199).
C II

n. No recommendation can be made about the routine use of sheathed endoscopes(137-140;200).

C II

3.5. Recommendations for Accessories

a. Ultrasonic cleaning should be used for reusable endoscopic accessories to remove soil
and organic material from hard to clean areas(1;3;4;11;85;129;201).
C II

b. Biopsy forceps are classified as critical items. If reusable, they must be steam sterilized
after cleaning. Chemical sterilization does not penetrate the coils and is not effective. If
disposable items are used, discard after use(1;3;4;47;58;85;129;189).
B II

c. Other accessories that penetrate mucosal barriers (i.e., papillotomes, cytology brushes)
should either be disposable or sterilized between patient use (high level disinfection is not
appropriate)(3;4;11;85;129).
B II

d. The water bottle used to provide intra-procedural flush solution and its connecting tubing
should be sterilized or receive high-level disinfection at least daily. The water bottle
should be filled with sterile water(1;3;4;11;36;85).
B II

e. Each Endoscopic Retrograde Cholangiopancreatography (ERCP) procedure requires a

fresh sterile bottle filled with sterile water(1;11;33;101).
B II

64
 3.6. Storage and Transport
a. Valves and other components should be detached from the endoscope as per
manufacturer’s instructions, thoroughly dried and stored separately(1;9;11;93;141).
B II

b. Endoscopes should be stored uncoiled, hanging vertically in a clean, dry, ventilated area
that prevents recontamination or damage(1;3;4;6;9;11;16;85).
C II

c. The storage area should be cleaned weekly with an approved low level
disinfectant/cleaner(1;11).
C II

d. The maximum allowable storage time before reprocessing is required is 7 days(11;143-

146;202)
.
B II

e. A carrying case should be used exclusively to transport the used instrument and not used
for storage. Once placed in the carrying case, the instrument will be considered not
patient ready and will require reprocessing before being used(9;11;85).
C II

f. If a case is needed to transport the processed endoscope, it should be designated for this
purpose and well marked. Do not use the same case to transport used and reprocessed
scopes(147).
C II

4. Recommendations for Endoscopy Unit Design

a. All settings where endoscopes are used and disinfected should be designed to provide a
safe environment for patients and healthcare workers. Design should accommodate
proper workflow from dirty to clean with adequate separation to minimize risk of cross
contamination(4;11;167).
C II

b. Reprocessing areas should be physically separate from patient procedure

rooms(6;8;11;16;167).
C II

65
 c. The procedure room should have a separate, dedicated hand-washing sink with hands-
free controls. A separate hand washing station should be provided in the reprocessing
area(11;167).
C II

d. Air-exchange equipment (ventilation system, exhaust hoods) should be used to minimize

the exposure of all persons to potentially toxic vapours and air quality should be
monitored regularly(3;11;85). See Recommendations Section 5.2 (e).
C II

e. The reprocessing area should be under negative pressure and have an air-exchange rate
of, at minimum, 10 per hour(11).
f. Bronchoscopy procedures and patient recovery post bronchoscopy must be performed in
a negative pressure room with a minimum air-exchange rate of 12 per hour in newly
constructed isolation rooms or 6 per hour in existing facilities(168-170).
g. Clean storage space, which is physically separate from decontamination and cleaning
areas, should be provided. Storage space should have adequate positive pressure
ventilation(11;167;170).
C II

5. Recommendations for Quality Management

5.1. Personnel Education and Training

a. All healthcare personnel in any setting where gastrointestinal endoscopy and
bronchoscopy are performed should be trained in and adhere to Health Canada
Guidelines: Routine Practices and Additional Precautions for Preventing the
Transmission of Infection in Health Care(13),which includes the correct use and
requirement to wear personal protective equipment to protect both patients and healthcare
workers, and Hand Washing, Cleaning, Disinfection and Sterilization in Health Care(12).
For detailed recommendations, refer to Health Canada Guidelines: Routine Practices
and Additional Precautions for Preventing the Transmission of Infection in Health
Care(13) and Hand Washing, Cleaning, Disinfection and Sterilization in Health Care(12).
BI

b. Personnel assigned to reprocess endoscopes and accessories should receive hands-on

training with written device-specific reprocessing instruction for every endoscope model
and automatic endoscope reprocessor in their area of responsibility(3;4;6;7;11;85;91;125;127).
B II

66
c. Personnel should meet the healthcare setting’s written endoscope reprocessing
competency requirements. Documented competency testing should be carried out
initially after completion of training and subsequently on a regular basis (e.g., at least
annually). Additional training with documented competency should be provided for new
models of endoscopes or automatic endoscope reprocessors as they are introduced into
the practice setting;(11).
B II
d. Temporary personnel should not be allowed to reprocess endoscopes until competency
has been established(3;4;6;8;11;16;85;91;125;127).
B II

e. All personnel using chemicals should be educated about the biological and chemical
hazards present while performing procedures that use disinfectants/sterilants.
Occupational health and safety training should include the workplace hazardous materials
information system (WHMIS)(13).

5.2. Worker Health and Safety

a. Personal protective equipment (e.g., gloves, gowns, eye protection with visors or goggles,
and respiratory protection devices) should be readily available and should be used
routinely to protect workers from exposure to chemicals, blood or other potentially
infectious material. For detailed recommendations, refer to Health Canada
Guidelines: Routine Practices and Additional Precautions for Preventing the
Transmission of Infection in Health Care(13;159) and CSA Standard Z314.8-08:
Decontamination of Reusable Medical Devices(1-5;11;13;73;85;158;165).
b. A N95 respirator should be used during an endoscopic procedure if pulmonary or
laryngeal tuberculosis is suspected(5;101;165;203;204).
C II

c. All susceptible personnel should receive immunizations as recommended by the National

Advisory Committee on Immunization (NACI)(164) and receive tuberculin skin testing in
accordance with Public Health Agency of Canada guidelines(11;168).
BI

d. Established written protocols, in accordance with the healthcare facility’s Occupational

Health and Safety Program, should be in place to prevent and manage worker exposure to
infectious agents (e.g., HBV, TB) and toxic chemicals(3;4;12;85;124;128).
BI

67
e. Wherever chemical disinfection/sterilization is performed using products that produce
toxic vapours (e.g., glutaraldehyde), work areas need to be properly ventilated to ensure
levels are below threshold limit values (TLVs) specified in provincial and federal
Occupational Health and Safety (OH&S) regulations. Recirculation of air in the area
where the product is used is prohibited by OH&S regulation and ventilation must be to
the exterior)(11;34;65;101;114;121;128).

5.3. Reprocessing Program

a. Manufacturer’s written recommendations for use of sterilants/chemical disinfectants and
instructions for reprocessing should be followed(11;101;125;128).
BI

b. All manufacturer’s written recommended maintenance schedules and services for

endoscopes and automatic endoscope reprocessors used in the facility should be adhered
to(3;4;9;11;15;16;85;91;101).
C II

c. Visual inspections of equipment should be conducted to ensure that it is in proper

working order in accordance with the endoscope manufacturer’s recommendations and to
identify conditions that may affect the cleaning or disinfection processes(3;11).
B II

d. Routine testing of the liquid sterilant/high-level disinfectant should be performed to

ensure minimum effective concentration (MEC) of the active ingredient. Product-specific
test strips should be used. The solution should be checked at the beginning of each day of
use (or more frequently) and the results documented. If the chemical indicator shows that
the concentration is less than the MEC, the solution should be discarded. A log of test
results should be maintained(3;4;6;11;85;101).
B II

e. The liquid sterilant/high level disinfectant should be discarded at the end of its reuse life
(which may be single-use), regardless of the minimum effective concentration (6;11;23;205).
B II

f. Healthcare facilities should develop protocols to ensure that users can readily identify
whether an endoscope is contaminated or is ready for patient use(3).
C II

68
 g. A permanent record of reprocessing shall be completed and retained according to the
policy of the facility. The record shall include but not be limited to the patient’s name and
medical record number, the endoscopist, identification number and type of endoscope
(and automatic endoscope reprocessor, if used), date and time of the clinical procedure,
results of each individual inspection and leak test and the name of the person
reprocessing the endoscope(3;4;6;9-11;85;101;135;136;153;154;172;205-208).
BI

h. A surveillance system capable of detecting clusters of infections or pseudo-outbreaks

associated with endoscopic procedures should be established(76;205).
BI

i. Routine microbiologic testing of endoscopes for quality assurance purposes is not

recommended. If endoscope cultures are indicated (e.g., outbreak investigation), see
Appendix D for sample collection method and interpretive criteria(3;4;85;124;172).
C II

6. Recommendations for Outbreak Investigation and Management

a. If a cluster of suspected or confirmed endoscopy-related infections occurs, an
investigation should be initiated to determine the potential routes of transmission (e.g.,
person-to-person, common source) and reservoirs. Use standard methods for outbreak
investigation. Refer to Appendix H, Guideline for Outbreak Investigation Related to
Endoscopic Procedures(76).
BI

b. If a breach in protocol is recognized, a risk assessment should be initiated to determine if

patient notification is required(5;80;82;83;174).
BI

c. If a breach in protocol is recognized, an assessment and investigation should be

performed to determine why this happened and how to prevent a recurrence(174).
BI

d. Outbreaks of endoscope-related infections should be reported to persons responsible for

infection prevention and control, risk management and all involved department heads. If
there are public health implications, notify local public health authorities and Health
Canada. Where appropriate, notify the manufacturer(s) of the endoscope,
disinfectant/sterilant, and automatic endoscope reprocessor(3-5;9;11;23;80;85;101;122;205).
BI

69
7. Recommendations for Classic and Variant Creutzfeldt-Jakob Disease
(CJD and vCJD))
Refer to Health Canada/Public Health Agency of Canada Infection Prevention and
Control Guideline, Classic Creutzfeldt-Jakob Disease in Canada-Quick Reference-
2007(75) and “Classic Creutzfeldt-Jakob Disease in Canada”(209) for definitions of high
risk patient, high and low infectivity tissues, risk assessment tools and special
recommendations for cleaning and decontamination of instruments and surfaces that
have been exposed to tissues considered infective for CJD. The recommendations for
gastrointestinal and bronchoscopic endoscope reprocessing found in this section are
updated from those in the earlier Canadian CJD guidelines. The general procedures for
reprocessing endoscopes already outlined in this guideline should be followed. In
addition, the following are recommended for CJD.
a. Channel cleaning brushes and, if a biopsy has been taken, the valve on the endoscope
biopsy/instrument channel port should be disposed of as clinical waste after each use.
Single use biopsy forceps should be used(7).
C II
b. Disinfectants with fixative properties (e.g., aldehyde disinfectants) should not be used on
flexible scopes used for any procedure on patients with a diagnosis of definite, probable, or
possible CJD/vCJD, or where the diagnosis of CJD/vCJD is unclear(7).
BI
c. Following the decontamination of the endoscope, the automatic endoscope reprocessor
(AER) should be run through an empty cycle. Any solid waste or tissue remaining in the
AER should be removed together with the outlet strainer and disposed of by incineration.
Liquid waste should be disposed of safely by normal direct discharge from the AER. The
usual self-disinfection cycle should be run as per recommended routine. Endoscopic
accessories and cleaning aids should be disposed of by incineration(7).
C II
d. Endoscopes used for invasive (e.g., biopsy) procedures in individuals with definite,
probable, or possible vCJD, or where the diagnosis of vCJD is unclear, should be removed
from use or quarantined to be re-used exclusively on that same individual if required. The
endoscope should be fully cleaned and decontaminated alone using an automatic endoscope
reprocessor immediately after use, before being quarantined(7).
C II
e. If there is a risk that the endoscope could become contaminated with olfactory epithelium,
a single use endoscope should be used if possible. If this is unavailable the endoscope
should be removed from use(7).
C II

70
f. If it has been found retrospectively that an invasive endoscopic procedure was performed
on a patient suspected to have vCJD, endoscopy equipment should be managed as in 7d.
The instrument should be stored in a dated, leak proof, puncture-resistant container,
labelled “biohazardous”. The container should then be stored in a secure area and a
monitoring system should be in place to ensure that the instrument is not re-circulated into
the system until the diagnosis has been confirmed by neuropathological examination. If the
diagnosis is positive for vCJD, the instrument should be incinerated. If an alternative
diagnosis (i.e., not vCJD) is made, the instrument does not require CJD precautions, and
routine cleaning and sterilization/disinfection may be initiated(7;210).
C II
g. If it has been found retrospectively that an invasive endoscopic procedure was performed
on a patient suspected to have vCJD, reusable cleaning brushes that are still in use should
be disposed of by incineration.
C II
h. A record should be kept of each endoscope used for each patient. Refer to
Recommendation 5.3 (g) for details. This is important for any future contact tracing when
possible endoscopic disease transmission is being investigated.
C II

i. Outbreaks of endoscope-related prion infections should be reported to persons responsible

for infection prevention and control, risk management, all involved department heads and
the Public Health Agency of Canada CJD Surveillance Unit (phone 1-888-489-2999).
If patient and physician notification and follow-up are required, refer to Appendix H,
Guideline for Outbreak Investigation Related to Endoscopic Procedures.
C II

71
 APPENDIX A –PHAC IP&C Guideline Development Process

Literature Search – Inclusions/Exclusions

A thorough literature search was performed by the Public Health Agency of Canada reference
librarian in collaboration with the nurse consultant and the writer. The search results were
reviewed, and articles that did not meet the criteria for the guideline were eliminated. Abstracts
of remaining articles were examined; those that were not appropriate study designs or that failed
to meet specific methodological criteria were eliminated. As the essence of the guideline was
further defined, additional searches were conducted to ensure all relevant literature was captured.
All searches covered the period from 1996 onwards.

Formulation of Recommendations

This Guideline provides evidence-based recommendations. Guideline recommendations were

graded to differentiate between those based on strong evidence and those based on weak
evidence. Grading did not relate to the importance of the recommendation, but to the strength of
the supporting evidence and, in particular, to the predictive power of the study designs from
which that data were obtained. Assignment of a level of evidence and determination of the
associated grade of recommendation was done by the writer and was reviewed and approved by
the co-chairs and all Guideline Working Group members. When recommendations were not
unanimous, difference of opinion was formally recorded and the reasons for disagreement noted
for the information audit trail. It is important to note that no real divergence of opinion occurred
for this guideline, however when a difference of opinion occurred, debate took place and a
solution was found and accepted.

Where scientific evidence was lacking, the consensus of experts was used to formulate a
recommendation. The grading system is outlined in Appendix I.

External Review by Stakeholders

This Guideline was reviewed by a group of societies and associations for feedback on the quality
and content of the document and grading of recommendations for further validation before
widespread implementation. The reviewers were:

ƒ Association of Medical Microbiology and Infectious Disease Canada

ƒ Canadian Association of Clinical Microbiology and Infectious Diseases
ƒ Canadian Association of General Surgeons
ƒ Canadian Association of Thoracic Surgeons
ƒ Canadian Nurses Association
ƒ Canadian Standards Association
ƒ Canadian Thoracic Society
ƒ Central Service Association of Ontario
ƒ Community and Hospital Infection Control Association - Canada
ƒ Healthcare Infection Control Practices Advisory Committee
ƒ Network of Networks Interest Group, Community and Hospital Infection Control
Association-Canada
ƒ The Canadian Association of Gastroenterology
72
ƒ The Canadian Society of Gastroenterology Nurses and Associates
ƒ The Hospital for Sick Children

Editorial Independence

This guideline was funded by the Public Health Agency of Canada. Financial contribution was
provided by the Canadian Association of Gastroenterology for travel and hospitality costs for
non-public servants attending the expert working group meeting.

All Members of the Guideline Working Group have declared no competing interest in relation to
the guideline. It was incumbent upon each member to declare any interests or connections with
relevant pharmaceutical companies or other organizations if their personal situation changed.

The guidelines outlined herein are part of a series that has been developed over a period of years
under the guidance of the 2008 Steering Committee on Infection Prevention and Control
Guidelines. The following individuals formed the Steering Committee on Infection Prevention
and Control Guidelines:

ƒ Dr. Lynn Johnston, (Chair), Hospital Epidemiologist & Professor of Medicine, QEII Health
Science Centre, Halifax, Nova Scotia
ƒ Nan Cleator, National Practice Consultant, VON Canada, Huntsville, Ontario
ƒ Brenda Dyck, Program Director, Infection Prevention and Control Program, Winnipeg
Regional Health Authority, Winnipeg, Manitoba
ƒ Dr. John Embil, Director, Infection Control Unit, Health Sciences Centre, Winnipeg,
Manitoba
ƒ Karin Fluet, Director, Regional IPC&C Program, Capital Health Region, Edmonton, Alberta
ƒ Dr. Bonnie Henry, Physician Epidemiologist & Assistant, Professor, School of Population &
Public Health, UBC, BC Centre for Disease Control, Vancouver, British Columbia
ƒ Dany Larivée, Infection Control Coordinator, Montfort Hospital, Ottawa, Ontario
ƒ Mary LeBlanc, Carewest Infection Prevention & Control Coordinator, Tyne Valley, Prince
Edward Island
ƒ Dr. Anne Matlow, Director of Infection Control, Hospital for Sick Children, Toronto,
Ontario
ƒ Dr. Dorothy Moore, Infection Control, Division of Infectious Diseases, Montreal Children's
Hospital, Montreal, Quebec
ƒ Dr. Donna Moralejo, Associate Professor, Memorial University School of Nursing, St.
John’s, Newfoundland
ƒ Deborah Norton, Infection Prevention and Control Consultant, Regina, Saskatchewan
ƒ Filomena Pietrangelo, Occupational Health and Safety Manager, McGill University Health
Centre, Montreal, Quebec
ƒ JoAnne Seglie, Occupational Health Nurse OC RN, University of Alberta Campus, Office of
Environment Health/Safety, Edmonton, Alberta
ƒ Dr. Pierre St-Antoine, Professor of Medicine, Centre Hospitalier de l’Université de Montréal,
Campus Notre-Dame, Microbiology, Montreal, Quebec
ƒ Dr. Geoff Taylor, Professor of Medicine, Department of Medicine, Division of Infectious
Diseases, Edmonton, Alberta
ƒ Dr. Mary Vearncombe, Medical Director, Infection Prevention & Control, Sunnybrook
Health Sciences Centre, Toronto, Ontario

73
 APPENDIX B – Glossary of Terms

Automated Endoscope Reprocessor (AER): Machine designed to assist with the cleaning and
disinfection of endoscopes.

Antimicrobial agent: A product that kills or suppresses the growth of microorganisms.

Bacteria-free water: Water that has been filtered through a 0.2 micron filter to remove bacteria.

Bioburden: Population of viable microorganisms on a raw material, a component, a finished

product and/or a package.

Biofilm: The process of irreversible adhesion initiated by the binding of bacteria to a surface by
means of exopolysaccharide material (glycocalyx). The development of adherent microcolonies
eventually leads to the production of a continuous biofilm on the colonized surface. Bacteria
within biofilms tend to be more resistant to biocides than cells in batch-type culture.

Biomedical waste: Defined by the Canadian Standards Association (CSA) as waste that is
generated by human or animal healthcare facilities, medical or veterinary settings, healthcare
teaching establishments, laboratories, and facilities involved in the production of vaccines.

Cleaning: The physical removal of foreign material, e.g., dust, soil, and organic material such
as: blood, secretions, excretions and microorganisms. It is accomplished with water, detergents
and mechanical action. The terms “decontamination” and “sanitation” may be used for this
process in certain settings, e.g., central service or dietetics. Cleaning reduces or eliminates the
reservoirs of potential pathogenic microorganisms.

Contamination: The presence of microorganisms on inanimate objects (e.g., clothing, surgical

instruments) or microorganisms transported transiently on body surfaces such as hands, or in
substances (e.g., water, food, milk).

Critical items: Instruments and devices that enter sterile tissues, including the vascular system.
Critical items present a high risk of infection if the item is contaminated with any
microorganisms including bacterial spores. Reprocessing critical items involves meticulous
cleaning followed by sterilization.

Decontamination: The removal of disease-producing microorganisms, to leave an item safe for

further handling.

Disinfection: The inactivation of disease producing microorganisms. Disinfection does not

destroy bacterial spores. Disinfectants are used on inanimate objects; antiseptics are used on
living tissue. Disinfection usually involves chemicals, heat or ultraviolet light. Levels of
disinfection vary with the type of product used.

Drug Identification Number (DIN): In Canada, disinfectants are regulated as drugs under the
Food and Drug Act and Regulations. Disinfectant manufacturers must obtain a drug
identification number from Health Canada prior to marketing, which ensures that labelling and
supporting data have been provided and that it has been established by the Therapeutic Products
Directorate that the product is effective and safe for its intended use.

74
Endoscope accessory instruments: Medical instruments designed for insertion into a flexible
endoscope. These devices (other than the endoscope) are used during endoscopy and include, but
are not limited to, biopsy forceps, snares, bite blocks, guide-wires, irrigation tubes, and dilators.
Devices may or may not have lumens, porous or loosely joined surfaces or access ports for
flushing, and may or may not be capable of being completely disassembled during reprocessing.

Endoscope-Flexible: Flexible fiberoptic or video endoscope used in the examination of hollow

viscera (bronchoscope, colonoscope, duodenoscope, gastroscope, sigmoidoscope).

Enzymatic detergent: Low-sudsing cleaning formulations containing protease, lipase, amylase,

alone or in combination, that aid in the removal of proteinaceous material on medical
equipment/devices.

High level disinfection: Level of disinfection required when reprocessing semi-critical items.
High level disinfection processes destroy vegetative bacteria, mycobacteria, fungi and enveloped
(lipid) and non-enveloped (non-lipid) viruses, but not necessarily bacterial spores. High level
disinfection chemicals (also called chemisterilants) must be capable of sterilization when contact
time is extended. Items must be thoroughly cleaned prior to high level disinfection.

Infection: The entry and multiplication of an infectious agent in the tissues of the host.

a) Inapparent (asymptomatic, subclinical) infection: an infectious process running a course

similar to that of clinical disease but below the threshold of clinical symptoms
b) Apparent (symptomatic, clinical) infection: one resulting in clinical signs and symptoms
(disease).

Manufacturer: Any person, partnership or incorporated association that manufactures and,

under its own name or under a trademark, design, trade name or other name or mark owned or
controlled by it, sells medical equipment/devices.

Material Safety Data Sheet (MSDS): Descriptive sheet that accompanies a chemical or
chemical mixture, providing the identity of the material; physical hazard, such as flammability;
acute and chronic health hazards associated with contact or exposure.

Medical Device: Any instrument apparatus, appliance, material or other article, whether used
alone or in combination, including the software necessary for its proper application, intended by
the manufacturer to be used for human beings for the purpose of:

a) Diagnosis, prevention, monitoring treatment, or alleviation of disease.

b) Diagnosis, monitoring treatment or alleviation of or compensation for an injury, or
handicap.
c) Investigation, replacement, or modification of the anatomy or of a physiological process
or control of conception; and that does not achieve its principal intended action in or on
the human body by pharmacological, immunological, or metabolic means, but that may
be assisted in its function by such means.

Minimum effective concentration (MEC): Lowest concentration of active ingredient

necessary to meet the label claim of a reusable high-level disinfectant/sterilant.

75
Non-critical items: Those that either touch only intact skin but not mucous membranes or do
not directly touch the patient. Reprocessing of non-critical items involves cleaning with or
without low level disinfection.
Outbreak: An excess over the expected incidence of disease within a geographic area during a
specified time period; synonymous with epidemic.
Patient-ready endoscope: An endoscope rendered visibly free from debris after being subjected
to a validated cleaning procedure and, at minimum, a high level disinfection or sterilization
process. If liquid chemicals are used for disinfection, the endoscope must also be rinsed to ensure
that it does not contain residual chemicals in amounts that can be harmful to humans.
Personal protective equipment: Specialized clothing or equipment worn by staff for protection
against hazards.
Reprocessing: The steps performed to prepare a used medical device for reuse.
Reusable device: A device that has been designed by the manufacturer, through the selection of
materials and/or components, to be reused.
Risk Class: Classification assigned to a device involved in patient care based on the risk of
infection involved with the use of the device. Classes are critical, semi-critical and non-critical.
Single use/disposable device: A device designated by the manufacturer for single use only.
Sterilant: Chemical germicide that has been cleared by the Therapeutic Product Division of
Health Canada as capable of destroying all viable microorganisms, including bacterial spores.
Sterile: The state of being free from all living microorganisms.
Sterilization: The destruction of all forms of microbial life including bacteria, viruses, spores
and fungi. Items must be cleaned thoroughly before effective sterilization can take place.
Threshold limit value - Time-Weighted Average (TLV-TWA): Airborne concentration of a
substance to which all workers may be exposed day after day without experiencing any adverse
health effects.
Ultrasonic Washer: A machine that cleans medical devices by agitation caused by sound waves
which produce vigorous microscopic implosions of tiny vapour bubbles on the surface of objects
immersed in the cleaning chamber.
Use - life: Statement by the manufacturer of maximum number of days a reusable high-level
disinfectant/sterilant might be effective.
Validation: A documented procedure for obtaining, recording, and interpreting the results
required to establish that a process will consistently yield product complying with predetermined
specifications.
Verification: Confirmation by examination and provision of objective evidence that specified
requirements have been fulfilled.

76
 APPENDIX C – Spaulding Classification System

REPROCESSING
EXAMPLES OF METHOD
CLASS USE
DEVICES (MINIMUM
REQUIREMENT)
Cleaning followed by
-Stethoscopes intermediate or low
NON-
Touches intact skin level disinfection,
CRITICAL -Blood pressure cuffs depending on degree
of contamination
-Gastrointestinal
Touches mucous endoscopes Cleaning followed by
SEMI-
membranes and non-intact high level disinfection
CRITICAL -Bronchoscopes
skin (HLD)
-Cystoscopes
-Biopsy forceps
-Snares / Loop
Enters sterile tissue,
Cleaning followed by
CRITICAL vascular system or body -Surgical instruments:
sterilization
space
-Arthroscopes
-Laparoscopes

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 APPENDIX D – Bioburden Test Method

Sample collection usually requires two people. It may be feasible to have a staff person from
Infection Prevention and Control work with a staff person in the endoscope reprocessing area to
collect the samples. If Infection Prevention and Control staff are not available, reprocessing
personnel can perform the sampling, however, care must be taken to ensure aseptic technique
during sample collection.

1. Sample Collection
Staff should wear appropriate personal protective equipment (gloves, gowns, face shields).
Supplies
1. Sterile tubing connector suitable to attach to the umbilical suction barb (or other channels
if tested)
2. Sterile syringes; one for each channel to be sampled (30 cc for suction/biopsy channel
and air/water channel, 20 cc for other smaller channels)
3. Sterile container for collecting the sample (sterile urine specimen containers work well)
4. Sterile reverse osmosis (RO) water (adequate total volume to collect samples from each
channel; e.g., for a colonoscope ~ 50 mls, for a bronchoscope ~ 30 mls, for a
duodenoscope ~ 50 mls will be needed). Ideally separate 20 mls aliquots of sterile RO
water should be used for each channel sampled (this ensures that the risk of
contaminating the sterile RO water as a result of aspirating several samples from the
same container is reduced).
Ensure the specimen collection container is properly labelled. It will be necessary to ensure that
the suction valve and biopsy port are closed so that the fluid used to collect the sample is flushed
through the suction/biopsy channel (the air/water valve needs to be closed to collect the sample
from the air/water channel). Use sterile RO water to collect the sample from the channel. This
ensures that the optimal sample will be collected as RO water is very “active” and will “strip”
surface material more efficiently than buffer or both media. In addition, it will not have to be
cleaned away and as such will not interfere with subsequent use of the scope on patients.
Method
1. Aspirate 10 mls of sterile RO water into a sterile 30cc syringe.
2. Attach this syringe via a piece of sterile tubing (e.g., manufacturer’s recommended
connector) to the suction/biopsy barb of the umbilical end and flush 10 mls of sterile RO
water through the channel.
3. Collect the channel sample from the distal end of the endoscope by holding the end of the
insertion tube in a sterile plastic container (urine specimen container can be used).
4. Use a syringe of air to flush out any residual fluid sample from the channel.

78
The sterile tubing used for sample collection should be packaged and steam sterilized prior to
next usage. The air/water channel can be sampled in a similar fashion by attaching a sterile piece
of tubing (e.g., manufacturer’s recommended connector) to the air/water barb on the umbilical
end and flushing 10 mls of sterile RO water through the air/water channel. For other smaller
channels that may be present on some flexible endoscopes (e.g., elevator wire channel and
auxiliary water channel) the same process can be performed using 3 mls of sterile RO water
instead of 10mls, injected using a sterile 10cc syringe.
Once the channel sample(s) have been collected, and adequately labelled, they should be sent
immediately to the microbiology laboratory for culture. If transit time is anticipated to be more
than 30 minutes, the sample(s) should be held on ice or refrigerated until cultured (samples
should not be held in the refrigerator longer than 24 hours prior to culture). This ensures that
microbial growth does not occur during storage.
2. Bacterial Culture
Method
1. Mix the sample well (e.g., vortex mixer)
2. Inoculate 0.1 mls of the sample onto a blood agar (BA) plate and a Sabaroud agar
(SA) plate.
3. Spread the inoculum over the entire surface of the media to allow quantitation of any
colonies that grow.
4. Incubate the BA plate aerobically at 35°C for 48hrs (the BA plate will detect a wide
range of organisms that might come from humans and/or the environment)
5. Incubate the SA plate aerobically at 30°C for 5 days (the SA plate at the lower
temperature will detect the presence of Methylobacter species, which is commonly
found in potable water).
If no growth is detected after 5 days of incubation the sample should be reported as having no
detectable organisms. If growth of organisms is detected, the number of colonies should be
counted and the colony forming units (cfu)/ml determined (cfu/ml = total number of colonies on
the entire plate/0.1 mls (e.g., If 10 colonies are detected, the cfu/ml = 10/0.1 = 100 cfu/ml).
3. Interpretation
How to interpret the presence of any detectable bioburden is controversial. One published
interpretation criterion is that endoscope channels would be expected to have bioburden levels
that are no worse than 200 cfu/ml, which represents the cut-off of viable microorganisms for
dialysis water and is within the 500cfu/ml or less cut-off (heterotrophic plate count, excluding
coliforms) accepted by Canadian guidelines for potable water(93). If there are 20 or more
colonies on the plate (e.g., 20 colonies per 0.1 mls = 200 cfu/ml), this is considered unacceptable
and would be reported as 200 cfu/ml. If 1 - 19 colonies are detected, this is considered
acceptable, as a few organisms may be present due to the collection method. This result would be
reported as < 200 cfu/ml. If no growth is detected the result would be reported as “no growth”.

79
4. Actions for Unacceptable Bioburden Levels
If the level of bioburden is ≥200 cfu/ml, then the scope should be removed from use and re-
tested. If the second testing shows no problem, then the scope can be returned to use (i.e., the
elevated bioburden level was an isolated situation that is not due to an ongoing process problem).
If the bioburden level is ≥200 cfu/ml. on the second evaluation, then infection prevention and
control needs to be contacted to identify what the problem might be and recommend solutions.
At this stage testing of all scopes may be necessary to determine how wide-spread the problem
is. Items to be assessed (not an exhaustive list) when unacceptable bioburden levels are
repeatedly detected include:
• Was there residual moisture in the channels during storage (review the procedure for
alcohol rinsing and forced air drying prior to storage)? This is the most common reason for
sporadic unacceptable bioburden levels.
• Was the cleaning being done properly (review cleaning process to ensure fresh detergent
was prepared for each scope)?
• Is the high level disinfectant still effective (review daily minimum effective concentration
(MEC) testing results)?
• Was the final rinse post-high level disinfection (HLD) contaminated (check filter integrity
if using an AER, take samples of the final rinse water from the distal side of the filters to
determine bioburden levels)?
• Is there a problem with the high level disinfectant? To evaluate whether this is a problem,
bioburden testing should be performed (sample collected as described previously)
immediately after HLD to assess if the disinfection stage is ineffective.
If HLD problems are identified, Infection Prevention and Control should review the charts of
patients on whom this scope had been used since the time of the last testing to evaluate if there
have been any potential patient-related problems. If potential patient infections are identified, an
assessment should be performed to determine the need for further outbreak investigation and/or
patient notification.
The data from bioburden testing and any follow-up investigations should be reviewed with
Infection Prevention and Control at the time of the occurrence.

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 APPENDIX E – Sample Audit Checklist for Reprocessing of Medical
Equipment/Devices

NOTE: This checklist was adapted from Sunnybrook Health Sciences Centre
Purpose:
All medical equipment/devices used in healthcare settings in Ontario are to be reprocessed in accordance
with both the Ministry of Health and Long-Term Care "Best Practices for Cleaning, Disinfection and
Sterilization", Public Health Agency of Canada infection prevention and control guidelines and current
CSA standards.
Definition:
Reprocessing refers to the steps performed to prepare used medical equipment/devices for reuse.
Responsibility:
Each Physician Program Head and/or department manager is responsible to verify that all medical
equipment/devices reprocessed in the area for which he/she is responsible is being reprocessed according
to the Ministry of Health and Long-Term Care Best Practices for Cleaning, Disinfection and Sterilization
in All Health Care Settings.
Checklist: Department/Area to be Audited

ITEM YES NO PARTIAL COMMENTS

Reprocessing occurs in the area (if no – sign off checklist is

complete)

Single-use medical equipment/devices are not reprocessed.

Personal protective equipment is worn when cleaning

reprocessing (eye protection, mask, gown and gloves)

Cleaning

Equipment/devices are cleaned using an enzymatic cleaner

prior to reprocessing

Is cleaning done in a separate area from where the

instrument will be used i.e., designated dirty area)

High Level Disinfection

Equipment/devices are subjected to high-level disinfection

according to manufacturer's instructions, using an
approved, high-level disinfectant (do not keep high-level
disinfectant for more than 2 weeks even if test strip is still
okay)

High-level disinfectant concentration is checked daily

Quality Control on test strips is carried out as per company

guideline

Test strip bottle is dated when opened

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 ITEM YES NO PARTIAL COMMENTS

Test strips are not used past the manufacturer's expiry date

Log is kept of results of high-level disinfectant quality

control

Log is kept of instruments that receive high-level

disinfection

Log is kept of dates when high-level disinfectant is changed

Two staff sign off that the correct solution was used when
high-level disinfectant is changed

Automated reprocessor has preventive maintenance

program

Log is kept of all preventive maintenance

Log is kept of all maintenance associated with reprocessor

Using checklist for reprocessing of endoscopes

Sterilization

Equipment/devices are sterilized by an approved

sterilization process

Bowie Dick – done daily – high vacuum sterilizer

Sterilizer physical parameters are reviewed after each run

Log is kept of physical parameters

Sterilizers monitored with biologic monitor daily (each type

of cycle, i.e., flash, long loads)

Log is kept of biologic monitors

Sterilizer has a preventive maintenance program

Log is kept of preventative maintenance

If biologic monitor is positive, loads are recalled and the

positive test is investigated

Log is kept of all maintenance associated with a positive

biologic monitor

Indicator tape is used on outside each wrapped package

Multi-parameter indicator used on inside each wrapped

package containing 2 or more instruments

Log is kept of each loan and items in load

If flash sterilization is used, a log is kept of flash sterilizer

use

Flash sterilized equipment/devices are noted in the patient's

chart along with reason

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 ITEM YES NO PARTIAL COMMENTS

All logs are to be retained according to facility policy.

All reprocessed equipment/devices are stored in a manner

to keep them clean and dry.

Chemical indicators are checked before equipment/devices

are used

Is there a process in place that clearly identifies a non-

reprocessed instrument from one that has been reprocessed
to prevent use on a patient

Purchasing and Reprocessing Instructions

Manager/purchaser is aware of purchasing policy for all

medical equipment/devices requiring reprocessing.

There are explicit written reprocessing instructions from the

manufacturer on each equipment/device to be reprocessed.

Policy & procedure for reprocessing are written. These are

compatible with current published reprocessing standards
and guidelines.

Education

Manager and staff are educated on how to reprocess

instruments when:
ƒ First employed
ƒ Minimum of annually
ƒ Any authorized change in process
ƒ When new equipment is purchased – reprocessor
ƒ When new equipment is purchased – medical
equipment/devices requiring reprocessing

Managers and staff have completed a recognized

certification course in reprocessing or there is a plan to
obtain this qualification with 5 years

There is an audit and follow-up process in place for

ongoing evaluation of reprocessing. Appropriate people
and Infection Prevention & Control are notified when
follow-up is required.

Compliance with the Occupational Health and Safety Act

R.S.O. 1990, c.O.1 and associated Regulations including
the Health Care and Residential Facilities – O.Reg. 67/93
Amended to O.Reg. 631/05.

Checklist Auditor: Date:

83
 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 A. Endoscope is wiped and flushed immediately following procedure
manufacturer's recommendations for cleaning
B. Removal of debris collected in scope (brushing)
C. Removal of debris collected on the scope (surface cleaning)
D. Perform a Leak test
E. Visually inspect the scope to verify working properly

2. Verify that endoscope can be reprocessed in site's A. Documentation from endoscope's manufacturer confirming
automated endoscope reprocessor (AER) compatibility of each scope with AER
B. Documentation from AER manufacturer confirming testing of
individual scope in system.
C. Specific steps before reprocessing endoscope's in AER

3. Compare reprocessing instructions provided by A. Conflicts identified and resolved.

AER manufacturer and scope manufacturer and
resolve conflicts. B. Compliance with manufacturer's recommendations for hospital
approved chemical germicide

4. Adhere to endoscope manufacturer's instructions A. Manual procedures in place for endoscopes not compatible with AER
for manual reprocessing in the absence of specific
technical information on AER reprocessing. B. Compliance with manufacturer's recommendations for hospital
approved chemical germicide.

5. Reprocessing protocol incorporates a final drying A. All channels of reprocessed endoscopes are flushed with alcohol
step. followed by purging with air.

6. Staff adheres to facility's procedures for A. Confirm AER's processes are applicable to specific endoscope's models.
preparing endoscope for patient.
B. Ensure endoscope-specific reprocessing instructions from AER mfg are
correctly implemented.
C. Written, device-specific instructions for every endoscope's model
available to reprocessing staff.
D. Written instructions for reprocessing system are available to
reprocessing staff.

84
 Recommendation Specific Procedure Yes/No/NA MRP Comment/Strategy for Improvement

7. Comprehensive and intensive training is provided A. New reprocessing staff receives thorough orientation with all
to all staff assigned to reprocessing endoscopes procedures.
B. Competency is maintained by periodic (annual) hands on training with
every endoscope model and AER used in the facility.
C. Competency is documented following supervision of skills and
expertise with all procedures.
D. Frequent reminders and strict warnings are provided to reprocessing
staff regarding adherence to written procedures.
E. Additional training with documented competency for new endoscope
models or AER

8. A comprehensive quality control program is in A. Periodic visual inspections (monthly) of the cleaning and disinfecting
place. procedures.
B. A scheduled endoscope's preventive maintenance program is in place
and documented.
C. Preventive maintenance program for AER is in place and documented.
D. Preventive maintenance program for all reprocessing system filters is in
place and documented.
E. AER process monitors are utilized and logged.
F. Chemical germicide effectiveness level is monitored and recorded in a
logbook.
G. 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.
H. There are records documenting the serial # of scopes leaving the
Endoscope reprocessing area (e.g., repairs, loaners, O.R., etc.)
I. There is a surveillance system that detects clusters of
infections/pseudoinfections associated with endoscopic procedures.

85
 Recommendation Specific Procedure Yes/No/NA MRP Comment/Strategy for Improvement

9. Staff adheres to Routine Practices. A. Ensure correct hand hygiene technique is performed in appropriate
situations.
B. There is compliance with procedures for wearing clean, non-sterile
gloves.
C. PPE (masks, eye protection, gown, plastic apron) is worn during
procedures and patient care activities that are likely to generate splashes
or sprays.
D. Appropriate PPE is worn during scope cleaning and reprocessing.
E. Heavily soiled linen is placed into plastic bag prior to depositing in
linen hamper.
F. Procedures are in place to prevent sharps injury.
G. Staff is knowledgeable regarding protocol for follow-up for blood/body
fluid exposure.

10. Endoscope reprocessing policies and physical A. All procedures are in compliance with federal/provincial Occupational
space are in compliance with workplace Health and Safety regulations/legislation
regulations and standards.
B. The reprocessing physical space is in compliance with the Canadian
Standards association standards and federal/provincial Occupational
Health and Safety regulations/legislation.

86
 APPENDIX G – Verification of Training Stages for Endoscope Reprocessing

Date(s) of Training:

Name of Trainee:

Name of Trainer:

Information or Procedure in Verification that procedure training was

Verification of competency with procedure
Endoscope Reprocessing Training provided

Trainer: Trainee: Trainer: Trainee:

1. Basic tutorial on:

• Use of flexible endoscopes
• Mechanics/handling of scopes

2. Infection prevention and control tutorial on:

• Basic microbiology of endoscopy
• Disease transmission, staff protection
(reduce aerosolizing)
• Prevention of infection transmission -
(patient to patient, environment to patient
transmission)

3. Chemical and detergent usage and safety

4. Review of reprocessing manuals:

• Manufacturer’s procedure manual
• Site/unit procedure manual (including
diagrams)

5. Leak testing:
• How
• Why
• When
• What to do if leak test fails

87
 Information or Procedure in Verification that procedure training was
Verification of competency with procedure
Endoscope Reprocessing Training provided

Trainer: Trainee: Trainer: Trainee:

6. Disassembling of endoscopes:
• Remove all buttons, valves, caps and other
removable parts
• Processing of disassembled parts
• Appropriate capping for video endoscopes
• Visual inspection
• Correctly dispose of parts that are deemed
single use

7. Manual cleaning procedure:

• Bedside suction
• Detergent used
• Brushing
• Appropriate size
• Appropriate reprocessing
• Water for rinsing (volume)
• Elevator wire of Endoscopic Retrograde
Cholangiopancreatography (ERCP) scopes
and other specialty channels
• Consistency of process and why this is
critical
• Visual inspection

8. Manual high-level disinfectant procedure:

• Appropriate preventive clothing/risk of
aerosols
• Hazards of chemical exposure
• Appropriate high-level disinfectant
• Testing
• Minimal effective concentration of
disinfectant
• Maximum in disinfectant expiratory date
• Appropriate immersion techniques
• Critical minimum timing parameters for high
level disinfectant exposure
• Rinsing techniques (water issues) of
endoscopes
• Alcohol rinse of endoscopes
• Drying of reprocessed endoscopes

88
 Information or Procedure in Verification that procedure training was
Verification of competency with procedure
Endoscope Reprocessing Training provided

Trainer: Trainee: Trainer: Trainee:

9. Automated endoscope reprocessor equipment:

• Manual pre-cleaning shall be done
• Appropriate protective clothing
• Hazards of chemical exposure
• Review of reprocessor manual/use of
machine
• Correct connection of endoscope
• Issues related to the use-dilution of high level
disinfectant or sterilant
• Alcohol rinsing of endoscope
• Drying of reprocessed endoscope

10. Storage of dried scopes

11. Accessory devices: appropriate cleaning and

disinfection

12. Quality assurance program for endoscopy:

• Reprocessing damaged endoscopes
• References
• Templates

Adapted from M. Alfa(211).

89
APPENDIX H – Guideline for Outbreak Investigation Related to Endoscopic
Procedures(90;172;174;205)

The steps below may be done simultaneously and do not always follow the order listed.

1. Identify the duration and nature of exposure (identify microorganism(s) of concern).

2. Identify which scope, and/or scope accessories were used and quarantine if necessary.
3. Notify all involved personnel (e.g., infection prevention and control, endoscopy director and nurse
manager, administration, microbiology, clinical department heads, communications department and
family MDs).
4. Advise laboratory to save all relevant patient and endoscope isolates.
5. Identify and count cases or exposures.
a. Create a case definition.
b. Develop a patient line listing: sort according to the procedure, endoscope used, and
chronological order in which accessories are used.
c. Perform chart review of cases for risk factors related to suspect procedure(s) or other
known risk factors for the infection under consideration; if review indicates endoscopy-
related infection, perform retrospective chart review of all patients undergoing the
procedure(s) for linked cases of post-endoscopy infection.
6. Tabulate and orient the data in terms of time, place, and person.
7. If indicated, perform environmental sampling of endoscopes, rinse water, fluid from automated
endoscope reprocessor (AER) and other. relevant items (e.g., water bottles, I.V. sedatives). Save
environmental isolates and compare with patient isolates to determine strain relatedness.
8. Formulate hypothesis for suspected outbreak.
9. Implement control and preventive measures.
10. Evaluate epidemiological data on the strength of causal association.
11. Initiate surveillance for new cases as well as continued microbiologic culturing of endoscopy
equipment.
12. Re-evaluate specific control and preventive measures and revise if necessary
13. Communicate findings.
a. Notify local public health and the Public Health Agency of Canada if there are public health
implications.
b. Prepare written reports for administration, involved department heads, and other requesting
authorities.
c. Provide information and debriefing sessions to involved personnel.
d. Notify the communications department and advise if patient follow-up is required.
14. Assess risk to the patient.
15. Develop plan for patient follow-up (only if required).
a. Organize a small notification team.
b. Develop a telephone script, contact letters, and fact sheets for patients and physicians (family
and attending).
c. Initiate telephone contact with the patient followed by written confirmation with fact sheet.
d. Provide information to the patient regarding required blood work and arrangement for follow-
up testing if necessary.
e. Notify diagnostic laboratory if a large volume of tests is necessary; may be advantageous if
lab requisitions for required tests are filled out for each patient and faxed/delivered to lab.
f. Plan for managing patients who test positive.

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 APPENDIX I – PHAC Guideline Rating System

PHAC Guideline Rating System(212)

Categories for the strength of each recommendation

Category Definition
A Good evidence to support a recommendation.

B Moderate evidence to support a recommendation.

C Insufficient evidence to support a recommendation.

Categories for the quality of evidence on which recommendations are

made

Grade Definition

I Evidence from at least one properly randomized, controlled trial.

II Evidence from at least one well-designed clinical trial without

randomization, from cohort or case-controlled analytic studies (preferably
form more than one centre), from multiple time series, or from dramatic
results in controlled experiments.

III Evidence from opinions of respected authorities on the basis of clinical

experience, descriptive studies or reports of expert committees.

When regulations are quoted, no rating is given as they are legislative requirements.

91
 Reference List

(1) Canadian Society of Gastroenterology Nurses and Associations. Infection control:

recommended guidelines in endoscopy settings. Canadian Society of Gastroenterology
Nurses and Associations 1998;1-13.

(2) Provincial Infectious Diseases Advisory Committee (PIDAC). Best Practices For
Cleaning, Disinfection and Sterilization In All Health Care Settings. 2006.

(3) Nelson DB, Jarvis WR, Rutala WA, et al. Multi-society guideline for reprocessing
flexible gastrointestinal endoscopes. Infect Control Hosp Epidemiol 2003;24:532-7.

(4) Alvarado CJ, Reichelderfer M. APIC guideline for infection prevention and control in
flexible endoscopy. Am J Infect Control 2000;28:135-55.

(5) British Society of Gastroenterology Endoscopy. BSG Guidelines For Decontamination of

Equipment for Gastrointestinal Endoscopy. British Society of Gastroenterology
Endoscopy; 2003.

(6) SGNA Practice Committee. Standards of Infection Control in Reprocessing of Flexible

Gastrointestinal Endoscopes. Chicago, IL: SGNA Headquarters; 2008.

(7) ASGE Standards of Practice Committee, Banerjee S, Chen B, et al. ASGE STANDARDS
OF PRACTICE COMMITTEE, Banerjee S, Shen B, Nelson DB, Lichtenstein DR, Baron
TH, Anderson MA, Dominitz JA, Gan SI, Harrison ME, Ikenberry SO, Jagannath SB,
Fanelli RD, Lee K, van Guilder T, Stewart LE. Infection control during GI endoscopy.
Gastrointest Endosc. 2008 May;67:781-90.

(8) American Society for Gastrointestinal Endoscopy. Reprocessing of flexible

gastrointestinal endoscopes. Oak Brook, IL: American Society of Gastrointestinal
Endoscopy; 1995.

(9) Mehta AC, Prakash UBS, Garland R, et al. American College of Chest Physicians and
American Association for Bronchology Consensus Statement: Prevention of Flexible
Bronchoscopy-Associated Infection. Chest 2005;128:1742-55.

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