The Importance of Manual Reprocessing in an Era of Automatization
I have been active in the endoscopic field for the last 30 years, and it is amazing to experience the progress that has been made. Endoscopes are becoming increasingly advanced, smart technologies are improving our treatment options and the reprocessing cycle is being streamlined.
Although the field has come a long way, endoscope contamination and the prevalence of infections remain serious issues. There are still too many reported cases. As physicians, we have the responsibility to address this. We are responsible for taking care of our patients and through collaboration with the industry, we have the opportunity to continue advancing patient safety in endoscopy. We must progress our understanding of endoscope contamination and come up with innovative ways to continuously improve patient safety.
Endoscope reprocessing: a complex process
In a recent study I conducted with colleagues, we found that 13% of endoscopes in the Netherlands still contain oral or gastrointestinal (GI) bacteria after reprocessing (Rauwers et al., 2020). The question arises: where do such contaminations stem from? Breaches in the reprocessing cycle are a causal factor, however there are also many instances whereby there were no reported breaches. These cases likely have to do with the complex design of the endoscopes and their complex mechanisms, such as multiple channels or elevator caps, and the difficulty of eliminating bacteria from these.
Endoscope contamination often also has to do with the complex reprocessing cycle, which has undergone many changes over the years. It begins with bedside flushing, which is followed by (manual) pre-cleaning and automated High‑Level Disinfection (HLD) (Rutala & Weber, 2014). The margin of safety when decontaminating scopes is rather delicate, as compared to the process of sterilization, which renders the current endoscope cleaning process susceptible of residual bacterial continuation. What makes this even more difficult is, if a breach happens at the beginning of the reprocessing cycle, the subsequent steps cannot transcend this. Especially in this time of antimicrobial resistance (AMR), whereby it is becoming increasingly difficult to treat a range of infections, it is important to keep finding ways that minimize the risk of endoscope contamination.
Marrying manual and automized processes
Automated endoscope reprocessing (AER) is an exciting new development in the reprocessing room. This offers a controlled, standardized and traceable solution for the pre-cleaning phase, which decreases the bioburden and endoscope contamination. Scholars have confirmed this: one study found a clinically relevant decrease of positive cultures from 23% to 15% when endoscopes were automatically pre-cleaned, as opposed to manually pre-cleaned (Shang Renduo et al., 2023). AER also minimizes waste generation and resource usage, so these solutions equally improve the environmental footprint of the endoscopy suite.
Recent innovations, such as the AquaTYPHOONTM from PENTAX Medical, embody these promises well. This automated, flexible endoscope pre-cleaning solutions improves the adequacy of cleaning. It reduces waste be combining only water and air, without the need for consumables or chemistry.
The AquaTYPHOONTM is one of many examples that is improving the reprocessing cycle and contributing to decreased endoscope contamination. Other exciting avenues include the creation of disposable elevator caps, which addresses the difficulty of disinfecting duodenoscope’s elevator mechanisms.
I would like to conclude with the following: we are increasingly moving into an era of automation, but I truly believe manual (pre-)cleaning will remain a quintessential part of the cycle. In the end endoscopy is all about people, whether it’s endoscopy nurses, reprocessing staff, or physicians. We must work together to find novel solutions that continue to enhance the efficiency of this process, and safeguard our patients’ safety.
Ulrike Beilenhoff and I discussed minimizing infection risks in endoscope reprocessing on the latest episode of Patient Safety in Endoscopy – the Podcast:
