Basic Information Fields
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Facility
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Department
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Conducted on
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Environment
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Reprocessing of contaminated equipment occurs in an area designated and dedicated for this function. It is separate from where procedures are performed.
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There is adequate space for reprocessing activities.
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Air flow and ventilation requirements are met
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Dirty to clean workflow patterns are followed.
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Work surfaces are appropriate for performing HLD. (solid surface & cleanable)
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Utilities are adequate to perform HLD safely. (adequate lighting, electrical support, hand washing facilities, eye washing facilities, etc.)
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Eye wash log is checked per policy.
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Appropriate PPE is available for HLD. (appropriate gloves, fluid resistant gowns, eye protection and surgical masks that will not trap vapors)
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Pre-Cleaning
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Pre cleaning of equipment begins as close to the point of use as possible.
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Equipment is wiped with a cloth or sponge soaked in freshly prepared detergent solution.
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Cloth/Sponge is either disposable or high level disinfected between uses.
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Detergent is suctioned into the biopsy/suction channel of the scope until the fluid is clear as part of the pre-cleaning process. (alternating detergent and air is most effective in the removal of debris from the lumen)
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Transportation
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Equipment to be high level disinfected is transported to the reprocessing area in an enclosed container that is large enough to prevent damage to the equipment and that will prevent contamination during transport.
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Leak Testing
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Leak testing is done before immersion of the endoscope in reprocessing solutions to minimize damage to parts of the endoscope not designed for fluid exposure according to manufacturer's recommendations.
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All suction valves, air water valves and biopsy valves are removed prior to leak testing. Disposable parts are discarded.
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Equipment that does not pass the leak test is removed from clinical use and repaired.
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Cleaning
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The endoscope is cleaned with a freshly mixed solution of medical grade, low-foaming, neutral pH detergent prior to automated or manual disinfection.
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The detergent solution is discarded after each use.
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Detergent is diluted and used according to manufacturer's recommendations.
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The endoscope is disconnected and disassembled as completely as possible and all components are immersed in the detergent solution.
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All accessible channels are flushed and brushed to remove all organic and other residue.
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External surfaces and accessories are cleaned with a soft cloth, sponge, or brushes.
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Equipment is brushed until no debris appears on the brush.
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Cleaning brushes appropriate for the size of the endoscope channel or port.
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Cleaning items (brushes or cloths) are disposable or are cleaned and high level disinfected between uses.
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Accessories that break the mucosal barrier (biopsy forceps or other cutting instruments) are cleaned and sterilized between uses.
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Cleaned equipment is thoroughly rinsed with clean water to remove residual debris and detergent.
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Forced air is used to remove water from all channels and the endoscope is wiped with a soft lint-free cloth to prevent dilution of the liquid chemical germicide during HLD.
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Disinfection
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Equipment that contacts mucous membranes are at a minimum high level disinfected.
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The high-level disinfectant/chemical sterilant is compatible with the equipment being reprocessed and the AER used. (if applicable)
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An FDA-cleared sterilant or high-level disinfectant is used according to manufacturer's recommendations.
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The high-level disinfectant/chemical sterilant is tested for MEC according to manufacturer's recommendations and results are documented.
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The equipment is completely immersed in high level disinfectant/sterilant without undue coiling and there is a tight fitting lid to control vapors.
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Equipment is rinsed with water (sterile, filtered or tap) following high level disinfection.
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The water rinse is followed by a rinse with 70%-90% ethyl or isopropyl alcohol.
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Forced air is used after flushing all the channels with alcohol to facilitate drying.
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Storage
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Endoscopes are hung in a vertical position to facilitate drying in a well-ventilated, dust free area.
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Equipment is stored in a manner that will protect them from damage or contamination.
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A process is in place to for staff to easily identify which equipment has been properly disinfected and are ready for patient use.
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Record Keeping
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There is a process to verify the parameters on an AER are correct after maintenance is performed and actions are documented.
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Quality control of high-level disinfectant/ chemical sterilant test strips is performed per manufacturer's recommendations and documented.
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A log is present with the following information: Patient name, MR#, Procedure, Date, Endoscopist, AER identification number, Endoscope identification number. (preferably serial number)
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HLD parameters are verified at the end of each disinfection cycle and documented.
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High level disinfectants/chemical sterilant and corresponding test trips are not expired. (manufacturer's expiration date or maximum reuse date)
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Training and Competencies of staff performing HLD are performed whenever reprocessing becomes part of their job description and annually thereafter.
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