EXECUTIVE SUMMARY

Preventing infections through better facility and scope-cleaning practices takes a concerted effort on the part of surgery centers. Leaders must make this a quality improvement project, and develop and train staff to follow best practices.

Direct observation of whether staff wears personal protective equipment, completes checklists daily, and signs off on logs can help.

Sample checklist items on the endoscopy cleaning log for the post-anesthesia care unit include examining privacy curtains for visible soil.

One helpful change is to hire additional staff to give technicians more time for scope cleaning and to streamline the process.


Infections attributed to contaminated scopes have made headlines and cost healthcare organizations and scope manufacturers millions of dollars over the past few years.

This makes scope cleaning an important best practice and quality improvement project for surgery centers. It is among the reasons why The Endoscopy Center of Encinitas, CA, focused on this process improvement, says Jill Smith, RN, infection preventionist of The Endoscopy Center. After implementing quality improvement process changes, the center improved its proper cleaning compliance rate to 98%.

“We had been looking at different areas where we felt we could do a better job,” Smith says. “With GI procedures, it’s always changing, like the national reports on duodenoscopes and people having infections and the difficulties in cleaning them. We thought this is where we needed to get educated and see what we could improve.”

The surgery center launched quality improvement/quality assurance processes, looking at procedure room cleaning, scope cleaning, and reprocessing.

“We took it a step further and said, ‘How can we do a doublecheck on cleaning processes of our scopes?’” Smith says. “We put our scopes in a processor, but how well are we manually cleaning these scopes?”

This question launched a study and has resulted in the surgery center collecting several years of data. The information led to continuous process changes. “We made huge changes, and it was eye-opening in the scope cleaning. We have had really great success with that,” Smith reports. The changes led to the center’s proper cleaning compliance rate increasing from 86% to 98%. “We continue to enjoy a success rate of 98% to 100% now that the process has become second nature,” Smith says.

Another outcome was that the room turnover time has improved. It once ranged from six minutes to 19 minutes. Under the streamlined, uniform approach to the cleaning process, it is consistently six to eight minutes, Smith adds.

What follows are the best practice steps The Endoscopy Center has taken to achieve positive outcomes:

Collect direct observational data. “We watched the room turnovers to see how people were doing it, and we were surprised at how different the rooms would look, depending on who did the turnover,” Smith says. “Some went above and beyond.”

They also observed contact times and dwell times to see if employees adhered to manufacturers’ instructions for use, waiting the full two minutes (if that was specified), Smith adds. “Any kind of disinfection or wipe or product has to stay wet for a certain amount of time for it to kill what it says it will,” she observes. “If you wipe it and then put something down on the surface or if the surface doesn’t stay wet, then you’re not getting disinfectant qualities, according to the manufacturer’s instructions.”

Direct observation worked well. It included observing whether staff wore personal protective equipment as required and whether they completed checklists daily (including signing off on logs). “We decided it needed to be streamlined,” Smith says. “We had a meeting and talked about the times of disinfectants, high and low surfaces, and we developed a flow that starts at the door and goes counterclockwise.”

Leaders also developed a checklist and used a timer. “We don’t do it anymore, but we also added a timer so when you wipe, you hit the timer, which was set for two minutes to make sure we were being conscientious of the dwell time,” Smith explains. “We instituted that change, and have gone back and remeasured and made tweaks, as necessary.”

Develop a checklist. As part of quality assurance, Smith presented the observation data to the staff and asked what they thought about it and what they would think of a change. She used staff feedback to develop a checklist. Before rolling out the checklist, Smith asked staff to assess it, asking them how useful it was.

“You can’t make change in a bubble,” she explains. “If you want to make a change, you have to have people who are invested in it.”

There are three checklists. Now, the cleaning process is automatic, and the checklists are available for new staff to use. “We also use an end-of-the-day terminal cleaning checklist, and they sign it off every day,” Smith says. “Someone looks at this checklist and confirms these things were done.”

Some sample checklist items on the endoscopy cleaning log for the post anesthesia care unit include: glucometer and thermometer cleaned after each use at end of day, all high-touch areas cleaned properly, and privacy curtains examined for visible soil and professionally cleaned as needed.

The endoscopy cleaning log also lists standards instructions, such as: dwell time is three minutes; high-touch areas include, but are not limited to, computer keyboards, side rails, phones, carts, door handles, call light, and clipboards; and all patient care area floors are properly wet-mopped at the end of the day by contracted services provider.

Implement new processes and monitor progress. After implementing the tool, Smith conducted observations over the first month, sometimes one or two per week. She also conducted 10 to 12 spot checks in the first month.

“Then, I took my direct observations to see if the checklist was being used,” she says. “We took that data, looked at it, and saw whether it was working and whether we were seeing more compliance.” Smith studied employees’ routines and looked for processes to tweak. This observational monitoring occurred monthly at first. Now, Smith conducts these on a quarterly basis and also checks the logs each month.

“I try to get five to 10 observations in a quarter of different people doing turnover in the recovery room to make sure we’re on the same page,” Smith says. “If we have a new hire, it’s part of their orientation to make sure they understand it.”

As nurse managers work, they can secretly observe room turnovers, Smith says. “I don’t just stand there with a clipboard and say, ‘Ready, go,’” she says. “I do a secret shopper observation.”

Infection prevention and best practices in cleaning and disinfecting are continual quality improvement projects. “Every year, when I write my infection control plan, it’s a hot button. My staff knows it’s always going to be this way,” Smith explains. “When working in a procedure room where we are dealing with infectious fluids, we have to be mindful and be committed as staff and administration.”

Make changes as needed. Quality improvement processes need to be evaluated continuously and changed when necessary.

For example, Smith’s center was using a product with a long dwell time. Employees were not keeping the surface wet for as long as the instructions advised. “They didn’t know they had to keep it wet for five minutes,” she says. “We knew that long dwell time wouldn’t work when we were turning over rooms as soon as possible.”

The solution was to change the wipe to wetter products with far shorter dwell times. But even this change took time to perfect. Leaders found that one-minute wipes were hard on some material and incompatible with the equipment, Smith recalls.

“We had to switch to something less caustic to equipment in the room,” she says. “Now, we’re using a two-minute prep, but have bigger wipes that are wetter and cover the surface better.”

This change is monitored and reviewed continuously. “We make it part of our yearly compliance when we do our annual education,” Smith says.

Another process change involved the endoscopy cart. Previously, the focus was on cleaning the dirty endoscopy cart. This has changed. Now, the surgery center’s focus is on looking at the room holistically for cleaning and decontamination. “If you have a dirty door handle and no one wiped it, and you touch it before going to a patient, the potential for infection is high,” Smith explains. “We know better and can do better, and that’s what we did.”

Changes often require more resources. In The Endoscopy Center’s case, this meant administrators added another tech to allow more time for scope cleaning and to streamline the process. The center added more work to scope cleaning, which includes a channel check, extra checks and balances, and increasing scope cleaning time. “We separated the tasks,” Smith says. “Instead of [putting the cleaning] all on the technician, it’s split between the nurse and tech.”

Nurses come into a room and perform an environmental cleaning. They own responsibility for the room to make sure the cleaning happens. After completing the initial cleaning and waiting for the dwell time, the nurse collects medication and reviews the patient’s history. Then, the tech comes into the room and prepares the new scope and equipment for the next case, Smith explains. Before, the cleaning was left mostly to the technicians, who would say they did not have enough time. Physicians believed the cleaning process took too long. “We realized that someone had to take ownership, so we figured out a new, streamlined process and tried it,” Smith says. “There was some grumbling in the beginning, and it was bumpy at times.”

But after the new process was first studied and then implemented and remeasured, staff began to see its benefits. “It works very well now,” Smith reports. “No nurses quit over this change, and it helped us more as a team because we worked on it as a team.”