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5.4 Manual Cleaning & Rinsing

CLEANING

1. Make up enzymatic solution 
Make up fresh enzymatic detergent solution to the manufacturer's instructions for reprocessing each endoscope. Fresh solution prevents cross contamination.

2. Immerse instrument 
Completely immerse the endoscope.

Whenever practical, leave the endoscope immersed in the detergent solution when performing all subsequent cleaning steps to prevent the production of aerosols of contaminated fluid.

Immersion of Endoscope

3. Disassemble removable parts and clean

• Remove all buttons/valves/caps and other removable parts (if you have not already done so).
• Correctly dispose of parts designated as single use.
• Brush and clean non-disposable parts with a small soft brush paying particular attention to internal surfaces and lumens.
• Place buttons and valves in an ultrasonic cleaner.

The endoscope must be completely disassembled so that all surfaces may be reached for thorough cleaning.

4. Brush and wipe exterior

• Wash all debris from outer surfaces by brushing and wiping the instrument.
• Use a soft toothbrush to gently clean the distal tip.
• Brush control handles and biopsy port.
• Brush around valve seats and clean thoroughly.

Use of non-abrasive and lint-free cleaning tools will prevent damage to the endoscope.

Soft toothbrushes are useful to clean grooved handles and to brush the distal tip.

Valve seats and biopsy ports should be brushed using brushes supplied by the manufacturer which are designed for this purpose.

Cotton buds may be used to clean the suction valve port but should not be used in the air/water port as threads can become caught and cause blocked channels.

Check that all visible debris has been removed.

Cleaning brushes for valve ports are available from manufacturer.

5. Brush all channels

• Brush all accessible endoscope channels including the body, insertion tube and the umbilical cable or universal cord of the endoscope.
• After each brush passage, rinse the brush tip in the detergent solution, removing any visible debris before retracting the brush and reinserting it.
• Continue brushing until there is no debris visible on the brush.
• Finish brushing process with use of valve port brush to remove any debris which has been translocated to this area from brushing the channels.
• Clean and thermally disinfect or sterilise reusable brushes prior to reuse.

Cleaning brushes for all brushable channels are supplied by the manufacturer.

Use a brush size compatible with each channel. Rinsing the brush tip maximises cleaning of the channels by ensuring that as much debris as possible is removed before retraction or reinsertion.

Cleaning and thermally disinfecting brushes reduces the risk of contamination of endoscopes by inadequately cleaned brushes.

Inspect reusable brushes between uses and replace when bristles are worn, frayed, bent, if the shaft is kinked or the brush is otherwise damaged.

Worn bristles are ineffective in cleaning and damaged brushes may damage endoscope channels.

Bladed cleaners are an alternative to bristle brushes. Follow manufacturers instructions for use.

Brushing Channels

6. Properties of effective cleaning brushes

Brushes should: 

• meet the endoscope manufacturer's specifications
• fit the channel being cleaned
• be the correct length and diameter for the channel
• pass easily through the channel without excessive friction
• be able to be sterilised or single use
• be cost effective

Bristles should be:

• stiff enough to cause dislodgment of debris
• size and length appropriate to the channel
• extend to the tip of the brush

Shafts should not kink during use or cause channel damage
 

7. Attach cleaning adaptors if required

• Check the manufacturer's instructions.
• Fit the manufacturer's cleaning adaptors for special endoscope channels (e.g., elevator channel, forward water jet, double channel endoscopes).
• Flush all channels thoroughly with enzymatic detergent solution
• Immerse the endoscope and its internal channels for the contact time specified on the label of the enzymatic detergent.
• Discard detergent solution after each use.

All endoscopes are supplied with appropriate cleaning adaptors. It is vital that persons cleaning endoscopes are conversant with these adaptors and use them correctly.

Substitute cleaning equipment should not be used unless approved by the supplier of the instrument, e.g. using a syringe to squirt fluid into a port which requires a screw thread adaptor is not safe practice.

Rubber "0" rings on the adaptors must be inspected regularly for defects or looseness and should be replaced as required.

In order to achieve adequate flow through all lumens, various adaptors or channel restrictors may be required.

Flushing all channels removes debris, expels bubbles and ensures that the detergent is in contact with all surfaces of the channels.

All channel entrances must be under the surface of the detergent to ensure that no air enters the channel when the endoscope is immersed.

Product specific contact time is required to allow enzymes to penetrate organic material.

If there is a delay prior to further processing due to emergency circumstances, the endoscope can be left soaking in a container of enzyme solution for a short period only.

Fill Channels with Detergent

RINSING

1. Water rinse

• Rinse outer surfaces of the endoscope with water
• Flush all channels throughly with water
• Remove all buttons / valves from the ultrasonic cleaner
• Rinse all removable parts with clean water

Clean running water should be used to remove all traces of detergent prior to disinfection.

The use of clean water for each endoscope will limit the potential for cross infection.

The amount of water required to throughly rinse the endoscope after cleaning will vary according to the design and length of the instrument.

Flushing Channels with Water

 

 

2. Dry external surfaces

• Dry the outer surfaces of the endoscope with a soft, lint-free disposable cloth

3. Purge internal channels with air

• Purge water from all the channels with air to remove rinsing water

Removing water from all channels and the exterior of the endoscope prevents dilution of the biocide used for disinfection.

This process can be completed using a syringe or compressed air. If using compressed air see the Final drying before reuse section for information about air pressure.

Purging with Air

5.5 Manual High-level Disinfection

It is imperative that the endoscope is thoroughly cleaned, rinsed and fluid is evacuated from all channels, before commencing high level disinfection.

1. Prepare biocide

• Prepare the biocide according to the manufacturer's label instructions.

Follow the manufacturers recommendations of concentration, time and temperature to achieve high level disinfection.

Only chemicals registered with the TGA as a high-level instrument grade disinfectant are to be used. See the Cleaning, Disinfection and Sterilisation module for more information on chemicals available in Australia.

• Test the minimum effective concentration (MEC ) of the biocide.

Test on each day of use or more frequently as dictated by the number of endoscopes being reprocessed.

The MEC may not be used to extend the use-life claim of the biocide.

Use a biocide specific test strip.

Keep a log of the test results.

See the Quality Assurance module for more information about monitoring the MEC.

 2. Immerse in biocide 
Completely immerse the entire endoscope in biocide.

Immerse biopsy caps, buttons/valves that are not able to be steam sterilised in the biocide.

Immersion of Endoscope in Biocide

 

3. Inject biocide into all channels and lumens

• Fill all lumens and channels with biocide so that all air bubbles are expelled. ensure that biocide is seen to emerge from all the ports at the distal end of the insertion tube and light guide connector.
• It is essential to expel all air from the channels in order to ensure that all internal surfaces are in contact with the biocide.

Fill Channels with Biocide

4. Immersion

• Leave the endoscope immersed in the biocide for the time/temperature/concentration required to achieve high level disinfection according to the manufacturers and TGA recommendations.

All channel entrances must be under the surface of the biocide to ensure that no air enters the channels.

Only use containers that allow for the immersion of the entire endoscope and which can be cleaned.

Cleaning adaptors should remain attached until after final rinsing and drying. This helps to vercome the potential for error that may occur due to failure to correctly reconnect all lumens.

Use a timer with an alarm to ensure that accurate immersion times are achieved.

A fluid thermometer with digital readout is recommended to constantly monitor temperature of the biocide.

Documentation of reprocessing parameters must be completed for each endoscope as part of proof of process.

5. Purge with air

• Purge the biocide completely from all channels with air
• Remove endoscope, buttons/valves/caps from biocide, taking care to avoid drips and splashes.

Purging the channels preserves the concentration and volume of the biocide and prevents exposure from drips and spills.

Purging with Air

FINAL RINSE

1. Immerse in rinse water

• Immerse endoscope and buttons/valves/caps in rinse water

Rinsing removes any chemical residue that may cause injury to skin and mucous membranes.

Use clean running water for each endoscope to ensure all traces of biocide are flused away and to limit the potential for cross infection.

To avoid contamination of the endoscope with environmental organisms such as Pseudomonas sp. and Mycobacteria sp., which may be present in unfiltered tap water, instruments intended for use in immunocompromised patients, or for invasive procedures e.g ERCP and bronchoscopy, shall be rinsed with sterile or 0.2mm filtered water.

Where filtered water is not used, it is absolutely essential to use alcohol flushing and prolonged air drying at the end of sessions for other flexible endoscopes.

The quality of water delivered to the endoscopy unit should be examined on a regular basis. If significant contamination is found then filters should be installed.

In small units or isolated areas where neither filtration nor regular bacteriological water testing is practical, then alcohol flushing and air drying for each endoscope is an acceptable alternative. 

See the water quality section in the QA module for more information about monitoring water quality.  
 
2. Flush all lumens and channels to remove all traces of biocide.

• Check the biocide manufacturer's instructions.

Different biocides may require different quantities of water to ensure removal of biocide residue when flushing channels.

Flushing Channels with Water

 

3. Rinse the exterior of the endoscope thoroughly.

4. Rinse all buttons/valves/caps thoroughly.

5.6 Final Drying

FINAL DRYING BEFORE REUSE

If the instrument is to be stored and not reused go to the next section called - final drying before storage.

1. Purge all rinsing water from all channels with air.

2. Dry all channels with pressurised air.

• Follow the manufacturer's instructions for the appropriate air pressures.

Avoid excessively high air pressure that can damage the internal channels of the endoscope.

As a general rule the maximum recommended air pressure is 21 psi (lbs per square inch) or 145 kPa, which is equivalent to 1.45 atm. It is important to check each instrument's manual.

Ensure that the air source has a flow regulator and use a lower air pressure on fine channels. use bayonet (leur slip) rather than luer lock fittings to attach the air tubing to the cleaning adaptors and fit securely but not tightly - if safe pressure is exceeded the bayonet fitting will give way.

3. Lubricate all 'O' rings on buttons, valves and store separately.

Lubrication is used to ensure optimal functioning of both endoscopes and accessories. The 'O' rings on suction and air/water control buttons require lubrication to prevent the buttons sticking in the depressed position.

Where silicone oil lubricants are used for suction and air/water control buttons, they should be applied immediately before the endoscope is used (after high level disinfection). It is essential to remove lubricant residue after use to allow biocide contact. Ultrasonic cleaning will remove any small remaining amounts of lubricant.

4. Reassemble the endoscope

• If the instrument is to be stored see the next section on final drying before storage.
• Remove the cleaning adaptors.
• Dry the exterior surfaces with a soft, clean, lint-free cloth.
• Reassemble the endoscope.

FINAL DRYING BEFORE STORAGE

At the end of the list when an instrument is being prepared for storage it is important to ensure that all channels are completely dry. Flushing with 70% alcohol assists the drying process.

1. Purge all rinsing water from all channels with air.

2. Flush all channels with 70% isopropyl alcohol until the alcohol can be seen exiting the opposite end of each channel.

Use approximately 2mls for the elevator channel and approximately 20mls for each other channel.

If using a multi-channel cleaning adaptor the quantities of alcohol may need to be increased.

Alcohol is used to aid pressurised air-drying.

Use alcohol that has been properly stored. Evaporation occurs rapidly if alcohol is exposed to air and if the concentration is below 70% it cannot be relied upon to assist in the drying process.

3. Dry all channels with pressurised air

Follow the manufacturer's instructions for the appropriate air pressures.

Avoid excessively high air pressure that can damage the internal channels of the endoscope.

As a general rule the maximum recommended air pressure is 21 psi (lbs per square inch) or 145 kPa which is equivalent to 1.45 atm. It is important to check each instrument's manual.

Ensure that the air source has a flow regulator and use lower pressure on fine channels. Use bayonet (leur slip) rather than leur lock fittings to attach the air tubing to the cleaning adaptors and fit securely but not tightly - if safe pressure is exceeded the bayonet fitting will give way.

The alcohol assists the evaporation of any residual water as the air flows through the channel.

4. Remove all channel adaptors.

5. Dry the exterior with a soft, clean, lint-free cloth.

Ensure that all outer surfaces are dry.

6. Check the instrument for any sheath or lens damage.

Polish the lens with the cleaner provided by the manufacturer.

DO NOT REASSEMBLE THE ENDOSCOPE

 

STORAGE

Cupboards used to store endoscopes must be either designed to hold endoscopes horizontally on a flat surface with continuous air flow through each channel, or be tall enough to allow scopes to hang vertically without touching the floor and be well ventilated or have continuous air flow through each channel. Endoscopes should not be stored in transport cases as these may themselves become contaminated.

Cupboards with continuous air flow must provide filtered air and alarms to notify staff if the air flow fails as there is no free air flow and impaired fluid drainage and evaporation of residual moisture when connected.  (Note: HEPA filtration is not required as there is no published evidence of endoscope contamination with airborne pathogens during storage).

Cupboards should be made of an impermeable material that allows for the cupboard walls to be cleaned weekly.Provided storage conditions are as recommended above, endoscopes will need to be reprocessed prior to use only when the times in the following table have elapsed.

 

Type of Endoscope	Storage Time
Gastroscopes, colonoscopes and radial EUS enteroscopes	72 hours
Duodenoscopes, bronchoscopes and linear EUS scopes	12 hours
Emergency endoscopes e.g. intubating bronchoscopes	72 hours, but preferably just before use if time permits
Enteroscopes	72 hours if stored with continuous air flow. 12 hours if hanging storage, as impractical to have hanging vertically without touching the floor.