Is your facility challenged by a less-than-ideal flow in the endoscope-reprocessing workspace? Never fear—we’re here to help. This column will explore workflow, physical separation of spaces, equipment placement and efficient processes.
Challenges with Endoscopy Reprocessing Areas
Endoscopy reprocessing areas in an outpatient setting are often challenged by space (or lack thereof). Typically, the areas are retrofitted into an existing location that often has inadequate room for all the equipment necessary to clean and high-level disinfect scopes. When dealing with existing spaces, it’s critical to reduce the risk for contaminating processed scopes.
Whenever possible, the endoscope-reprocessing areas should be separated. However, budgetary constraints, square footage of buildings, and the required areas for patient care often make this almost impossible. When separation of spaces is not possible, it’s essential to understand what is required to ensure small spaces are meeting minimum standards to reduce the risk of contamination, transmissions, and infections to patients and employees, the environment, and community.
Workflow
An adequate area should have a unidirectional flow, with good distance between spaces used for the various stages in processing. There should be sufficient space for workflow patterns that start with a soiled holding area and end with a high-level disinfection area—and finally, storage. The area should be designed to reduce the risks of bloodborne pathogen exposure to employees and devices.
There should also be precautionary measures to prevent cross contamination of processed scopes and processing equipment. When reviewing the space, assess how to prevent employee- related injuries (e.g., from having to lift or carry heavy items unnecessarily) and the possibility of microorganism growth in the reprocessing area.
Additional considerations include ensuring that all work sur- faces, ceiling tiles and counters are nonporous; corners should be rounded off to prevent injuries; and all work areas should be height adjustable or positioned to meet the average height of most employees. While washing and decontaminating devices, technicians must stand for prolonged periods of time, so anti-fatigue mats should be used to help prevent worker injuries.
Personal protective equipment (PPE)—impervious gowns, face shields, masks, gloves, bouffant caps and shoe covers— should be located at the entrance to the area. Shelves or closed cabinets can be placed outside the entry door or as soon as one enters the area. If stored inside the processing area, PPE should be contained to prevent it from becoming contaminated. All equipment and supplies should be stationed and stored in such a way as to reduce the number of times the technician needs to move back and forth. Everything in the room should be set up to induce a single directional flow pattern when the technician enters.
Physical Separation of Spaces
In a one-room reprocessing area, sufficient space allows for all tasks to be performed with ease. Reprocessing functions should not be performed in the same room as procedures; the only disinfecting process that can be performed in the procedure room is point-of-use cleaning. Policies and procedures should outline how point-of-use pre-cleaning of endoscopes should be performed, how scope accessories are cleaned, and how endoscopic components are transported from the procedure room to the reprocessing area. Flexible endoscopes should not be stored in procedure rooms.
The processing area should be a restricted space that is limited to designated personnel only. A sign reading “Restricted Area, PPE Required” should be posted outside of the door (in the case of a one-room setup). Otherwise, a sign requiring PPE should be posted on the entry door to the scope-cleaning room. A unidirectional flow should be considered when transporting devices from the procedure room to the decontamination area. A hand-off process (delivering items from one point to the other) of the soiled device to the processing technician should be developed and written in the policy.
Although physical separation for each process is preferred, it is not always possible. Partitions or dividers may be needed to reduce potential splash between spaces. For example, a plexiglass partition at least four feet high and four feet wide can be installed next to the final rinsing sink in the decontamination space to separate the contaminated space from the clean space.
The clean space can continue as an inspection station, cleaning verification space, and staging area until the scope can proceed to high-level disinfection. Then there should be an adequate space for drying scopes with instrument air. Perform a risk assessment to verify that all process steps follow a unidirectional workflow pattern, fill potential gaps, and identify potential risks and exposed areas of opportunity that need immediate correction.
Equipment Placement
Daily tasks require specific tools and equipment that may take up counter space and limit how that area can be utilized. When considering the placement of equipment necessary for endoscope-device reprocessing, the person organizing the space should analyze intended use for each piece of equipment. Reading all operational manuals and manufacturer instructions will help identify the equipment specifications and space required to use the equipment properly.
For instance, when cleaning flexible endoscopes, the Association for the Advancement of Medical Instrumentation (AAMI) recommends a sink with a minimum of two wells — three wells are preferred. Each sink should be long and deep enough for technicians to place the endoscopes into the sink well, loosely coiled, without causing damage. Most flexible GI endoscopes need a sink at least 36 inches wide and about 8-10 inches deep (AAMI, 2017). Other processing equipment should be assessed for the required space and for service or repairs.
When starting the decontamination process, there should be space to perform leak testing of the scopes. Space is also needed so technicians can visually inspect the flexible endoscopes under 10x lighted magnification. When counter space is limited, installing shelves or brackets can help free space where a leak tester and magnifying glass can be stationed.
Automated device flushing systems often require a significant amount of space. When considering purchasing, it’s very important to know how much total space is required and to assess where the flushing unit can be placed so that it does not take vital space needed for staging scopes and other supplies.
For clean workspaces, create a designated area to store supplies, manufacturers’ instructions for use (IFU), operational manuals, detergent, safety-data sheets and chemicals.
Most facilities are no longer manually high-level disinfecting their scopes; however, facilities that use manual soaking stations for high-level disinfection (HLD) of medical devices should have a designated area near a plumbing drain where technicians can pour and empty chemicals without creating splash or having to lift and carry heavy soaking and rinsing pans to a sink or drain. Placing the manual soaking station near a drain can prevent work injuries and chemical-exposure hazards.
When manual soaking stations cannot be located near a drain, it’s a good idea to use small lakeside carts with wheels so that the technician can slide the chemical- or water-filled pans onto the cart and push the cart to the drain and empty them safely. For employee safety, emergency eyewash stations and handwashing sinks should be in a designated clean area of the room, preferably by the exit. Eyewash stations should never be installed on the decontamination sink as this is considered contaminated. Employees should never flush their eyes or perform hand hygiene in a decontamination sink.
Automatic endoscope reprocessors (AER) that perform HLD are considered a clean activity, and so should never be placed next to or side by side with the decontamination space. At least four feet of distance is recommended. Although not ideal in areas where separation is not possible, partitioned walls can be installed to separate the decontamination space from the clean space. AAMI provides guidance and recommendations on how to properly separate one-room reprocessing areas. Storage cabinets should be placed and positioned in clean areas. Each scope in inventory should have enough storage space to prevent potential damage to the scope. Nothing else should be stored in the scope storage cabinet unless validated by the scope storage manufacturer.
Efficient Process
Dealing with existing spaces can be quite challenging. The most efficient process is mapped out in a way that allows technicians to be efficient, with all the needed equipment and supplies in the correct order, and all tools and resources readily available. Additional improvements can be made by utilizing color-coding systems to identify various brushes or supplies for specific pieces of equipment. Labeling and identifying each storage container and setting up par levels to keep inventory and supplies controlled will help technicians be more efficient as well.
All logbooks, manuals, safety-data sheets and paper materials should be stored in covered cabinets but identified with water-resistant labels (i.e., P-touch labels). Wipeable charts for cleaning processes, and information on how to start AER cycles and use the leak tester or flushing device, can be posted on walls or in a binder for quick reference.
Creating a highly functional space in the smallest areas can reduce the risk of hazard, make the area more user-friendly and provide safe and effective ways to reprocess flexible endoscopes properly. Patient and employee safety can be greatly reduced when proper assessments, planning, reviewing and organization of space is performed.
