Endoscope Reprocessing Toolkit

The resources in this toolkit may only be used for internal improvement and education efforts. They may not be used for commercial purposes.

Close adherence to established guidelines for reprocessing endoscopic equipment is essential to preventing the transmission of pathogens.

The ASC Quality Collaboration has assembled a variety of resources and information that may be used to supplement your current processes to enhance existing reprocessing practices.

The BASIC Endoscope Reprocessing Toolkit includes three essential resources:

• Endoscope Reprocessing: What CMS Surveyors Are Looking For
• Endoscope Reprocessing Policy Template
• Multi-society Guideline for Reprocessing Flexible Gastrointestinal Endoscopes

The EXPANDED Endoscope Reprocessing Toolkit contains both essential resources and a broader array of materials, including:

• Assessment Tools
• Implementation Aids
• Training Materials
• Monitoring Tools
• Workplace Reminders
• Guidelines from Leading Authorities

Comments and other feedback may be directed to Ann Shimek, Executive Director, ASC Quality Collaboration, ashimekco@gmail.com.

Assessment Tools

• Endoscope Reprocessing: What CMS Surveyors Are Looking For
  Perform a self-assessment using the same tool CMS surveyors use when evaluating reprocessing of endoscopes in the ASC setting.
• Endoscopy Department Checklist (HCA)
  This checklist from Hospital Corporation of America (HCA) allows assessment of policy and procedure elements, training and education, quality control and documentation for endoscope reprocessing.
• Endoscope Reprocessing Competency (UNC)
  This sample endoscope reprocessing competency review from the University of North Carolina (UNC) Health Care System may be adapted for use in the assessment of ASC staff.

Implementation Aids

• FDA-Cleared Sterilants and High Level Disinfectants
  This link leads to a list of agents that have been cleared by the U.S. Food and Drug Administration (FDA). It summarizes high level disinfectant contact conditions for each agent with an indication for high level disinfection.
• Guideline for Use of High Level Disinfectants & Sterilants for Reprocessing Flexible Gastrointestinal Endoscopes (SGNA)
  This 2017 guideline from the Society of Gastroenterology Nurses and Associates (SGNA) provides general information about the principles, product safety, and characteristics of high-level disinfectants and sterilants for reprocessing flexible endoscopes.
• Reprocessing of Endoscopic Accessories and Valves (SGNA)
  This 2014 position statement from the Society of Gastroenterology Nurses and Associates (SGNA) outlines best practices for the proper reprocessing of endoscopic valves and accessories.
• Reprocessing of Water Bottles Used During Endoscopy (SGNA)
  This 2014 position statement from the Society of Gastroenterology Nurses and Associates (SGNA) outlines best practices for the proper reprocessing of water bottles used in endoscopy.
• Automated Endoscope Reprocessors (ASGE)
  The American Society of Gastrointestinal Endoscopy (ASGE) issued this technology status evaluation report in 2016. It includes a discussion of key considerations in the use of automated endoscope reprocessors.
• Endoscope Reprocessing Policy Template
  This basic endoscope reprocessing policy template is based on the multi-society guidelines. It should be adapted as needed for use in each facility.

Training Materials

• Reprocessing Training Video for Olympus GI Endoscopes (Olympus)
  A series of training videos regarding the reprocessing of Olympus GI endoscopes is available at this webpage.

Monitoring Tools

• Scope Reprocessing Audit Tool (AmSurg)
  This sample endoscope reprocessing checklist from AmSurg may be adapted for individual center use.
• Endoscopy Safety Rounds Audit Tool (HCA)
  This audit tool from Hospital Corporation of America (HCA) allows monitoring of key elements of performance for safe reprocessing of endoscopes.

Workplace Reminders

• Reprocessing Protocol (SGNA)
  This poster from SGNA presents key steps in protocol-based reprocessing of gastrointestinal endoscopes.

Guidelines from Leading Authorities

• Preventing Cross-Contamination in Endoscope Processing
  This 2009 Safety Communication from the FDA, CDC, and the VA puts forth recommended steps healthcare facilities should take in reprocessing in order to limit patient risk from the use of flexible endoscopes and their accessories.
• Guideline for Disinfection and Sterilization in Healthcare Facilities (CDC)
  This 2008 guideline was developed by the Centers for Disease Control and Prevention (CDC) and Healthcare Infection Control Practices Advisory Committee (HICPAC). Detailed guidance on reprocessing of endoscopes begins on page 13 of the document.
• Multi-society Guideline for Reprocessing Flexible Gastrointestinal Endoscopes
  This 2016 consensus document presents evidence-based recommendations for endoscope reprocessing.
• Infection Control During GI Endoscopy (ASGE)
  This 2008 guideline from the American Society of Gastrointestinal Endoscopy (ASGE) includes a discussion of key concepts in the reprocessing of endoscopes.
• Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes (SGNA)
  These 2016 standards from the Society of Gastroenterology Nurses and Associates (SGNA) promote proper infection prevention practices during the reprocessing of flexible gastrointestinal endoscopes and accessories.