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HICPAC Sample Audit Tool: Reprocessing Flexible Endoscopes

FlexEndoReprocessing-AuditTool

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Hosam Gomaa
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660 views

HICPAC Sample Audit Tool: Reprocessing Flexible Endoscopes

FlexEndoReprocessing-AuditTool

Uploaded by

Hosam Gomaa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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HICPAC Sample Audit Tool: Reprocessing Flexible Endoscopes

HICPAC Sample Audit Tool: Reprocessing Flexible Endoscopes


Purpose: Facilities can use this sample Audit Tool document as a template to develop their own audit tool
specific to their endoscopes and evidence-based reprocessing practices. This sample tool is designed to be
used in conjunction with the Competency Verification Tool. Facilities are encouraged to use these tools
together to verify competency and audit current practice as well as to ensure that their practices are
consistent with “Essential Elements of a Reprocessing Program for Flexible Endoscopes – Recommendations of
the Healthcare Infection Control Practices Advisory Committee.”

Auditor: Date:
Audit Item Yes No Comments/Action
Precleaning
Precleans the flexible endoscope at the point of use.
Discards the cleaning solution and cloth after use.
Transporting
Transports the contaminated endoscope and accessories to the
endoscopy processing room as soon as possible after use.
Ensures the container or cart is labeled with a biohazard legend.
Leak Testing
Performs leak testing before manual cleaning if indicated.
Manual Cleaning
Uses a freshly prepared cleaning solution and does not add
additional products to the water unless recommended by the
manufacturer.
Completely submerges the endoscope and accessories.
Cleans exterior surfaces of the endoscope with a soft, lint-free
cloth or sponge.
Cleans all accessible channels and the end of the endoscope with a
cleaning brush of the length, width, and material recommended by
the endoscope manufacturer.
Uses a clean brush for each endoscope cleaning.
If the endoscope has an elevator, raises and lowers the elevator
throughout the manual cleaning process.
Brushes the accessible channels until no debris appears on the
brush.
Removes debris before retracting the brush back through the
endoscope.
Flushes the channels of the endoscope with the cleaning solution.
Manually actuates the valves during the cleaning process.
Flushes and rinses exterior surfaces and internal channels with
water until all cleaning solution and residual debris is removed.
Dries exterior surfaces and removable parts of the endoscope and
purges all channels with air.
Reprocesses reusable parts, accessories, and cleaning implements
according to the manufacturer’s instructions for use (IFU).
Disposes of single-use parts, accessories, and cleaning implements.

Adapted with permission from Guideline Essentials. Copyright © 2016, AORN, Inc, 2170 S. Parker Road, Suite 400, Denver, CO 80231.
All rights reserved. Page 1 of 3
HICPAC Sample Audit Tool: Reprocessing Flexible Endoscopes

Audit Item Yes No Comments/Action


Inspection
Inspects and evaluates endoscopes and accessories for
 cleanliness
 missing parts
 clarity of lenses
 integrity of seals and gaskets
 physical or chemical damage
 moisture
 function
Uses additional illumination and magnification for inspection, as
needed.
High-level Disinfection or Sterilization
Manually cleans the endoscope and accessories before mechanical
or manual high-level disinfection or sterilization.
Mechanical methods
Checks the expiration date of the high-level disinfectant or liquid
chemical sterilant before each use.
Uses a test strip or other FDA-cleared testing device specific to the
disinfectant or liquid chemical sterilant and minimum effective
concentration of the active ingredient for monitoring solution
potency before each use.
Positions endoscopes and accessories within the mechanical
processor to ensure contact of the processing solutions with all
surfaces of the endoscope.
Connects the endoscope to the mechanical processor correctly.
Verifies mechanical processing cycles are completed as
programmed.
Manual methods
Checks the expiration date of the high-level disinfectant before
each use.
Uses a test strip or other FDA-cleared testing device specific to the
disinfectant and minimum effective concentration of the active
ingredient for monitoring solution potency before each use.
Flushes and fills lumens and ports with the high-level disinfectant.
Completely immerses the endoscope in the high-level disinfectant
solution for the designated time according to the device and high-
level disinfectant solution manufacturer’s IFU.
Rinses the endoscope with water that meets the manufacturer’s
specification or as recommended by professional organizations
after disinfection.
May be required for both mechanical and manual methods
Flushes lumens using 70% to 90% ethyl or isopropyl alcohol
according to the endoscope manufacturer’s IFU.
Dries exterior surfaces and removable parts of the endoscope and
purges all channels with air.

Adapted with permission from Guideline Essentials. Copyright © 2016, AORN, Inc, 2170 S. Parker Road, Suite 400, Denver, CO 80231.
All rights reserved. Page 2 of 3
HICPAC Sample Audit Tool: Reprocessing Flexible Endoscopes

Audit Item Yes No Comments/Action


Sterilization
Packages and sterilizes endoscopic accessories that enter sterile
tissue or the vascular system per the health care facility’s policy
and procedure.
Storage
Wears clean gloves when transporting the endoscope to and from
the storage cabinet.
Based on the cabinet design, stores flexible endoscopes
horizontally or hangs them vertically so they do not coil or touch
the floor of the cabinet.
Stores the flexible endoscope with all valves open and removable
parts detached.
Stores sterile items in a sterile storage area.
Records
Processing records include
 date and time
 identity of endoscope and endoscope accessories
 method and verification of cleaning and results of cleaning
verification testing
 number or identifier of the mechanical processor or sterilizer
and results of process efficacy testing
 identity of the persons performing the processing
 lot numbers of the processing solutions
 disposition of defective items or equipment
 maintenance of water systems, endoscopes and endoscope
accessories, and processing equipment
Procedural records include
 date and time
 identity of the patient
 procedure
 identity of the licensed independent practitioner performing
the procedure
 identity of the endoscope and endoscope accessories used

Available from: https://www.cdc.gov/hicpac/recommendations/flexible-endoscope-reprocessing.html

Adapted with permission from Guideline Essentials. Copyright © 2016, AORN, Inc, 2170 S. Parker Road, Suite 400, Denver, CO 80231.
All rights reserved. Page 3 of 3

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