Endoscopy Decontamination Policy: Name Title Institution Date Signature Written by

ANH/IC&CSSD/POL/07/Vers.
01
Effective Date: January/ 2019
Endoscopy Decontamination Policy Review Date: January/ 2022
Institution Name: Al- Nahdha Hospital
Document Title: Endoscopy Decontamination Policy
Approval Process
Name Title Institution Date Signature
Written by Aziza Al-Maashari Infection Al- Nahdha January

prevention & Hospital 2019
control
Reviewed by Nada Al-Siyabi HOD infection Al- Nahdha January

control & CSSD Hospital 2019
Dr. Rasha Assistant Director Al- Nahdha January

Al- Abdwani of Medical & Para Hospital 2019
Medical
Validated by Quality Management Quality Al- Nahdha January
& Patient Safety Management & Hospital 2019
Department Patient Safety

Department
Approved by Dr. Hamad Hospital Director Al- Nahdha January
Al- Harthi Hospital 2019
Contents Table:
ANH/IC&CSSD/POL/07/Vers.01
Acronyms:......................................................................................................................................1
1. Introduction.............................................................................................................................2
2. Scope.......................................................................................................................................2
3. Purpose....................................................................................................................................2
4. Definitions...............................................................................................................................2
5. Procedure................................................................................................................................3
5.1 Infection control measures......................................................................................................3
5.2 Requirements.......................................................................................................................3-4
5.3 Design of decontamination.....................................................................................................4
5.4 Water quality monitoring....................................................................................................4-5
5.5 Procedure of decontamination................................................................................................5
5.5.1 Flexible endoscope.............................................................................................................6-8
5.5.2 Rigid endoscope....................................................................................................................8
5.5.3 Quality & monitoring.......................................................................................................9-10
6. Document History and Version Control...............................................................................11
7. References:..................................................................................................................12-13
Appendix 1............................................................................................................................14
Appendix 2............................................................................................................................15
Appendix 3......................................................................................................................16-17
Appendix 4............................................................................................................................18
Appendix 5............................................................................................................................19
Acronyms:
HCW Health Care Workers
EWD Endoscopy Washer Disinfector
Page 1 of 19
Endoscopy Decontamination Policy
1. Introduction
Effective cleaning and disinfection of endoscopes between clinical procedures is essential

in order to ensure that cross-contamination between patients does not occur. Endoscope
reprocessing according to standard guidelines ensures high-level disinfection and prevents
endoscopy-related infections. Moreover, Endoscopes should be cleaned as soon as possible
so that secretions do not dry and harden which makes cleaning much harder.
Manufacturer’s instructions should always be followed as well and staff should be familiar
with the structure of the endoscope and be trained in cleaning techniques and practices. In
this policy we will cover and discuss the endoscope reprocessing according to hospital
facility.
2. Scope
This guideline should be followed by HCW in all areas of endoscopy reprocessing in the
hospital.
3. Purpose
To provide a policy that can guide in cleaning and disinfection process of reusable flexible
endoscopes and its accessories in the health care area.
4. Definitions
4.1 Endoscope: is a lighted optical instrument that is used to get a deep look inside the
body. An endoscope, which may be rigid or flexible, can be used to examine organs,
such as the throat or oesophagus. Specialized endoscopes are named for where they
are intended to look. Examples include
the bronchoscope (bronchi), laryngoscope (larynx), otoscope (ear).
Page 2 of 19
5. Procedure
5.1 Infection Control Measures

Every patient must be considered a potential source of infection and all endoscopes
must be decontaminated with the same degree of rigor following every endoscopic
procedure. Lack of knowledge or unfamiliarity with endoscope channels, accessories,
and specific steps required for reprocessing has been linked to a risk of infection
transmission. Infection control measures that can disrupt the chain of infection
include:
5.1.1 Disinfection and sterilization of medical equipment.

5.1.2 Proper use of personal protective equipment, Standards of Infection Control in
Reprocessing of Endoscopes.
5.1.3 Personal hygiene.
5.1.4 Engineering controls (ventilation, room design, water supply).
5.1.5 Cleaning and disinfection of environmental surfaces.
5.1.6 Administrative monitoring and support.
5.1.7 Training and continuing education.
5.1.8 Written protocols.
5.2 Requirements
Proper endoscope reprocessing is critical to patient safety. For proper endoscope
reprocessing, the following elements are essential:
5.2.1 Pre cleaning at bedside.

5.2.2 Properly designed decontamination area with clear separation of Dirty/Clean
area.
5.2.3 Water Quality Monitoring.
5.2.4 Manual Cleaning.
5.2.5 Validation.
5.2.6 Transportation policies are in place.
5.2.7 Availability of written protocols.
5.2.8 Presence of Audit tool.
5.2.9 Staff training and competency.
Page 3 of 19
5.2.10 Storage.
5.2.11 Availability of tracking system.
5.2.12 Availability of endoscopes cleaning IFUs.
5.3 Design of decontamination area:

Design of the decontamination area is very critical and should designed in a way they
will prevent any contamination of the environment or recontamination of processed
endoscopes. The following essential elements should be there:
5.3.1 Physical Separation between clean and dirty area/activities.

5.3.2 Unidirectional flow of instruments from dirty to clean.
5.3.3 Room shall only be dedicated to reprocessing.
5.3.4 Personal Protective Equipment protocols for different area.
5.3.5 Clear labeling of the clean/dirty area (Decontamination area).
5.4 Water quality monitoring:

The quality of water can be measure by some factors that include:
5.4.1 Water hardness:

Many detergents and disinfectants are seriously impaired in their activity by
hard water.
5.4.2 Temperature:
The maximum temperature of rinse-water should be compatible with the items
being processed; flexible endoscopes are temperature-sensitive and may be
damaged by temperatures above 60ºC.
5.4.3 Ionic contaminants (for example heavy metals, halides, phosphates and
silicates):
Water used for the final rinse should have a chlorine level no higher than 10
mg/L. Chlorine levels exceeding this level should be reduced using a carbon
filter. (In some EWDs, a chlorine compound is added to the final rinse-water to
prevent microbial contamination).
5.4.4 Microbial contamination:
Appropriate treatment to control or reduce the microbial contamination in water
may be required.
5.4.5 Water deposits:
Page 4 of 19
Water deposits should be removed by filtration; otherwise they may affect endoscope
cleaning and disinfectant efficacy, and leave deposits inside endoscopes on
completion of the process cycle.
5.4.6 Bacterial endotoxins:
Endoscope washer-disinfector final rinse-water should not contain more than 30
endotoxin units/ml. Above this level there is a small risk that the toxin may affect the
patient after some procedures.
5.5 Procedure of decontamination:

The following table is a summary guide of the critical steps for the reprocessing of
flexible endoscopes. Please refer to the reprocessing manual provided by the
manufacturer for each endoscope being reprocessed. Different types and models of
endoscopes may require additional steps or different procedures to properly reprocess
the device. Personal protective equipment should be worn at all times during
reprocessing
5.5.1 Flexible endoscopes:
Step or procedure Important points to look in it. Rational

Pre cleaning at Perform pre-cleaning immediately 1) To help prevent the formation of
bedside 1) Wipe down the insertion tube of the biofilm.
endoscope with a soft lint-free 2) Reduces risk of worker and/or
disposable cloth or endoscope environmental contamination.
sponge soaked in freshly prepared
enzymatic detergent. 3) Removes gross debris and ensures
2) Flush the air/water channels as per patient material is not allowed to
the manufacturer of the endoscope. dry, which will impair
Flush all other channels with reprocessing.
enzymatic detergent solution at
bedside immediately post
procedure, followed by air.
3) Transport immediately in a covered
container to reprocessing area
before materials get dried ( or in
designated collection trolleys)
Page 5 of 19
Manual Cleaning 1) Leak test to be done (the dry test -remove from clinical use any endoscope
and the wet test) that fails the leak test and send for repair
2) Remove all of the valves, the distal -The most important aspect of the
end cap (if present) and any further process is the manual cleaning of
detachable components and instruments with detergent. The aim is to
submerge them in the detergent remove all blood, secretions and other
solution organic material prior to the surfaces
3) Stop watch should be available to coming into contact with the disinfectant.
maintain the socking time for each
solution.
4) immerse the endoscope in a freshly
prepared enzymatic detergent
solution (prepared as per the
manufacturer's instructions)
5) Clean all exterior surfaces of the
endoscope using a soft lint-free
cloth or endoscope sponge while
keeping the endoscope immersed.
6) Use endoscope brushes to clean
ALL channels while the scope is
immersed. (NOTE: not all channels
can be brushed - follow the
manufacturer’s recommendations
for channel cleaning). Repeat until
all debris has been removed.
7) Use the manufacturer’s cleaning
adaptors to ensure adequate
enzymatic detergent is flushed
through ALL channels (50 ml
Syringe can be used for flush)
8) Remove the endoscope from the
enzymatic detergent basin and
place in a basin filled with clean
water for rinsing.
9) Rinse all channels with an adequate
volume of water to remove all
detergent (At a minimum use
approximately three times the total
channel volume specific to the
endoscope being reprocessed.
Ensure a copious amount of water
is used to remove all enzymatic
Page 6 of 19
detergent). The use of potable tap

water for rinsing after endoscope
cleaning is acceptable.
10) Following the rinse, purge all
endoscope channels with air to
ensure removal of water. Wipe the
exterior surfaces of the endoscope
using a soft lint-free disposable
cloth to remove excess moisture.
11) Place the Scope in the disinfection
solution (After soaking for
recommended amount of time,
ensure adequate disinfection
solution is flushed through ALL
channels)
12) Transfer the endoscope and
components into a basin of fresh
rinse water (Distilled or
demineralized water). Fully
submerge the equipment. Use a lint
free cloth to wipe the exterior
surfaces of the endoscope.
13) Remove Endoscope from Rinse
Water and transfer the endoscope
and components into two more
basin of fresh Distilled water
followed by a sterile towel.
14) Drying the Endoscope - Use a
sterile, lint-free cloth to thoroughly
dry all external areas of the
endoscope.
15) Transfer immediately to storage
area.
Transportation  Follow the policy in transporting -To prevent endoscope damage and
both dirty and clean endoscopes as transmission of microorganisms.
to avoid any environmental
contamination and recontamination
of clean endoscopes.
 Transports the flexible endoscope

and accessories to the endoscopy
processing room in a closed,
Page 7 of 19
covered container as soon as

possible after use in designated
collection trolleys.
 Keeps the endoscope wet or damp,
but not submerged in liquid, during
transport.
 Two trolleys should be provided,
one to carry dirty container and the
other for clean container..
Storage There are two major types of storage  A storage area should be clean,
cabinets exist: well ventilated and dust free thus
 conventional storage cabinets: discouraging any microbial
-Hang endoscopes in a vertical position contamination (Use storage
(with caps, valves, and other detachable cabinets that are made of a
components removed) to prevent moisture material that can be disinfected).
accumulation and subsequent microbial  Since drying does not rely on
growth. gravity, the endoscopes can be
-Make sure that they hang freely so they stored horizontally or vertically
are not damaged by contact with one depending on the design of the
another and should not touch the floor. cabinet.
 drying storage cabinets:  Confirm that the endoscope is
-Follow the cabinet manufacturer’s stored in the ESC (Endoscope
instructions. Storage Cabinets) for no longer
than the validated time stated by
the ESC manufacturer.
5.5.2 Rigid endoscope:

Please refer to Appendix 2
Page 8 of 19
5.5.3 Quality monitoring and validation:
Sr. No Measures Frequency Responsibility
1. Documentation: With each -The doctor

 Procedure of endoscopy to be recorded in decontamination should record the
patient’s notes. serial number
 The endoscope serial number is documented -Endoscopy
in the patient’s notes. reprocessor
 Each reprocessing is recorded manually or
electronically, including the name of the
person.
 The process parameters of the washer-
disinfectors and automated disinfection
devices are documented by printouts or
electronically, to show that the reprocessing
cycle was successful and complete.
 All endoscopes have a record of their
decontamination such that they are ready for
use on patients.
2. Infection Control Audit for endoscope reprocessing Every 4 months ICP
area.
3. Staff training and competency Every 6 months Unit in-charge
ICP
TSD
4. Maintenance of washer-disinfectors and automated Daily/ Maintenance
disinfection devices: weekly/monthly
 To be cleaned and maintained on a daily according to task
basis according to manufacturer’s
recommendations
 Have regular engineering maintenance "
 Process validation for disinfection devices
must be done according to the
manufacturer’s instructions.
5. Periodic microbiological surveillance testing and Every 3months HSE
water quality. ICP
Sampling for routine tests: Endoscopy
 Endoscopes : reprocessor
a) Liquid samples from endoscope channels
after the disinfection & final rinse: flush the
appropriate channels with 20ml sterile saline
Page 9 of 19
and collect the liquid in a sterile container.

b) Swab from the outer surfaces of the
endoscope(e.g. swabs from distal end, valve
ports, bridge elevator)
 Final rinse water of washer-disinfectors:
Method is to take water sample by,
-Using a sterile syringe
-Collect the water in a sterile container,
-Sample volume: 2X100 ml
 Water supply:
Take water samples according to national
recommendations for testing of tap water.
Page 10 of 19
6. Document History and Version Control
Document History and Version Control
Version Description of Amendment Author Review

Date
01 Initial Release Aziza Al-Maashari Jan/2019
02
03
04
05
Written by Reviewed by Approved by
Aziza Al-Maashari Dr. Nada Al-Siyabi Hospital Director
7. References:
Title of book/ journal/ articles/ Website Author Year of Page
publication
Instruction manual of Karl Storz-Endoscope

Page 11 of 19
(Flexible Scope/Rigid Scope/Video-Rhino-

Laryngoscope).
World Health Organization. Decontamination and 2016

Reprocessing of Medical Devices for Health-care
Facilities
Guideline Summary: Processing Flexible 2016

Endoscopes, AORN Journal j, September, Vol.
104, No. 3,
http://apic.org/Resource_/TinyMceFileManager/I
mplementation_Guides/10_AORNGuidelineProce
ssingFlexibleEndoscopes.pdf,
Health Facilities Scotland and Health Protection

Scotland(NSH), Storage of Endoscopes in
Endoscope Storage Cabinets,
file:///C:/Users/user/Downloads/1497524083-
PRO-179-100-V1.0%20(1).pdf
Public Health Agency of Canada, INFECTION 2010

PREVENTION AND CONTROL GUIDELINE
for Flexible Gastrointestinal Endoscopy and
Flexible Bronchoscopy, http://www.phac-
aspc.gc.ca/nois-sinp/guide/endo/pdf/endo-eng.pdf
Health Technical Memorandum 01-06: March 2016,

Decontamination of flexible endoscopes(Part B:
Design and installation),
https://assets.publishing.service.gov.uk/governme
nt/uploads/system/uploads/attachment_data/file/5
30420/HTM0106_PartB.pdf
Society of Gastroenterology Nurses and 2012

Associates, Inc. (SGNA), Standards of Infection
Control in Reprocessing of Flexible
Gastrointestinal Endoscopes
https://www.sgna.org/Portals/0/Education/PDF/St
andards-
Guidelines/sgna_stand_of_infection_control_081
2_FINAL.pdf
U. Beilenhoff1, C. S. Neumann2, J. F. Rey3, H. 2007

Biering4, R. Blum5, V. Schmidt6 and the ESGE
Page 12 of 19
Guidelines Committee, ESGE–ESGENA

guideline for quality assurance in reprocessing:
Microbiological surveillance testing in
endoscopy(Endoscopy 2007; 39: 175 – 181),
https://www.esge.com/assets/downloads/pdfs/guid
elines/2007_quality_assurance_in_reprocessing.p
df
U. Beilenhoff1, C. S. Neumann2, J. F. Rey3, H. 2008

Biering4, R. Blum5, M. Cimbro6, B. Kampf7, M.
Rogers8, V. Schmidt9, and the ESGE Guidelines
Committee, ESGE–ESGENA guideline: Cleaning
and disinfection in gastrointestinal endoscopy
Update 2008(Endoscopy 2008; 40: 939 – 957),
https://www.esge.com/assets/downloads/pdfs/guid
elines/2008_cleaning_and_disifnection.pdf
World Gastroenterology Organisation/World

Endoscopy Organization Global Guidelines,
Endoscope Disinfection-a Resource-Sensitive
Approach(2019),http://www.worldgastroenterolo
gy.org/guidelines/global-guidelines/endoscope-
disinfection/endoscope-disinfection-english
Appendix 1: algorithm for flexible endoscopy decontamination
*Pre cleaning
Gently wipe the external Flush all other channels Transport in a

surfaces of the insertion with enzymatic covered container
tube with a cloth detergent solution (use rapidly to
moistened in detergent 50ml syringe) reprocessing area
solution.
Manual Cleaning
Page 13 of 19
Manual leakage test

Automated washer Manual reprocessing
Endoscopy
disinfectors Decontamination Policy Review Date: January/ 2022
All reprocessing steps are external

external and
and internal
internal cleaning
cleaning
Appendix
performed in 2: algorithm for rigid endoscope decontamination
washer- (Enzymatic
(Enzymatic detergent
detergent solution),
solution),
performed in washer-
disinfectors: brushing
brushing
disinfectors: Remove
Integrated leakage test Remove it it to
to clean
clean water
water for
for rinsing
rinsing
*Pre cleaning And
And ,
, Drying
Drying
Cleaning
Cleaning
Rinsing
Disinfection
Disinfection
Final
Final rinsing
rinsing Place the Scope in the disinfection solution
Drying (use a syringe to fill the channel with
Gently wipe the external
disinfectant solution)
surfaces of the insertion
tube with a cotton or Use Distilled Immerse the endoscope in Distilled water
gauze moistened in water for and
cleaning and Dryrinse
and rinse
with a
detergent solution.
rinsing lint free
cloth Clean all optical elements
Use a sterile, lint-freewith alcohol
cloth wipes or cotton
to thoroughly dry all
applicators soaked in 70%
external areas alcohol
Manual Cleaning (Disinfection Process)
Transfer immediately to storage

area
Disinfected or sterilized using a
*Perform Hand Hygiene and wear PPE prior to
glutaraldehyde soaking solution of
clean
2.5% (Exposure times should not Rinse the telescope
exceed 15 minutes) Dry with a
well with sterile soft sterile
water cloth
Sterilization
Endoscopes marked “autoclave”

Endoscopes NOT marked
“autoclave”
Steam sterilized can be up to 134 degrees C
Temperatures cannot be used (273 degrees F).
above 60 degrees C (140
degrees F)
After Pre cleaning process, Place the scope in a sterilization tray – allow
adequate space around the instrument to ensure proper circulation and
penetration of the steam.
Autoclave at 134 degree C for three minutes at 2.0

atmospheric pressure. (Do not exceed 5 minutes,
134C at 2.2 bars)
*Perform Hand After autoclave, allow the endoscopes to cool at
Hygiene and wear PPE room temperature for 1 hour before removing the
prior to clean top of the sterilization tray.
Page 14 of 19
Appendix 3: Flexible Endoscopes Procedure Audit Tool

Sr. Essential Quality Requirements Score Unit Remarks
No. awarded
1. Pre cleaning at bedside: (1)
 Perform pre-cleaning immediately ¼
 Gently wipe the external surfaces of the ¼
insertion tube with a cloth moistened in
detergent solution
 Flush all other channels with enzymatic ¼
detergent solution (use 50ml syringe)
 Transport in a covered container rapidly to
reprocessing area ¼
2. Separation Dirty/Clean area: (1)

 Physical Separation between clean and dirty ¼
area/activities
 Room shall only be dedicated to reprocessing ¼
 Personal Protective Equipment protocols for ¼
different area
 Clear labeling of the clean/dirty area
¼
(Decontamination area)
3. Water Quality Monitoring: (1)

 Maintain the temperature. ¼
 Chemical testing for water hardness and ionic ½
contaminants
 Microbiological testing for microbial ¼
contamination
4. Manual Cleaning: (3)
 Perform manual leakage test ½
 External and internal cleaning ¼
(Enzymatic detergent solution)
 Brushing ¼
 Rinse with water to remove detergent ¼
 Dry the scope in clean cloth ¼
 Place the Scope in the disinfection solution
(use a syringe to fill the channel with ½
disinfectant solution)
 Immerse the endoscope in Distill water and ¼
rinse
 Use a sterile, lint-free cloth to thoroughly dry
all external areas ¼
 Transfer immediately to storage area
½
5. Validation: (2)
 Validated AER 1
 Validated Manual cleaning 1
(To make sure that all steps and procedure is followed
Page 15 of 19
according to the policy such as correct concentration of

detergent and disinfection solution, maintain the steps
correctly)
6. Transportation policies are in place: (1)

 There is a clear policy or manual include
transportation method in a safe way.
7. Availability of written protocols: (1)

 Written protocol for the manual cleaning and ½
automated cleaning is available in the cleaning
area and where the endoscope is available.
 Protocols on the steps of endoscope ½
decontamination should be present and
available to all staff.
8. Presence of Audit tool: (1)

 Maintain the steps of reprocess of flexible
endoscope through audit tool.
9. Staff training (½) and competency(½) (1)
10. Storage**: (2)

 Adequate policies 1
 Protocols, access and Identification 1
11. Availability of tracking system: (1)

Tracking System for the process is documented in the
electronic documentation system to make sure each
reprocessing step was completed, resulting in patient-
ready endoscopes (Tracking for process not the
procedure)
12. Availability of endoscopes cleaning IFUs: (1)

 An Instruction for Use according to company
manufactures is available.
Name and Signature of Auditor: __________________________________

Name and Signature of Department staff: ___________________________
**Follow the guideline requirements.
Appendix 4: Flexible Endoscopes Reprocessing Competency Checklist
Page 16 of 19
Name: ______________________________ Date: _________________________

Dept.: ______________________________ Score: __________________________
 Staff working in endoscopy must receive training prior to performing decontamination. This should be
arranged locally by Ward In-charge with Infection Control Department.
 Clinical staff involved in endoscopy decontamination must have competency assessment. This should be
done by ward In-charge or infection control practitioner.
Sr.No Performance Criteria/ points Max Score Staff Remarks

Score awarded
Knowledge 1
1.  Staff is able to explain the repossesses procedure of

Flexible scope according to Endoscopy
Decontamination Policy 1
Endoscope Cleaning 6
2. Pre cleaning at bedside:
 Perform Hand Hygiene ¼
 Wears personal protective equipment (gowns, ¼

gloves, and eye protection)
 Perform pre-cleaning immediately ¼
 Gently wipe the external surfaces of the insertion ¼

tube with a cloth moistened in detergent solution
 visually inspecting the endoscope for damage ¼
 flush the channels of the endoscope alternately with ¼

the cleaning solution(enzymatic detergent solution,
to use 50ml syringe) and air (finishing with air)
 Discard the cleaning solution and cleaning gauze or ¼

sponge after use.
 Transport in a covered container immediately to ¼
reprocessing area
Transporting:
3.  Transports the flexible endoscope and accessories to

the endoscopy processing room in a closed container
as soon as possible after use. ½
 Keeps the endoscope wet or damp, but not ½

submerged in liquid, during transport.
Page 17 of 19
Leak test:
 Performs leak testing before manual cleaning and ¼

before the endoscope is placed into cleaning
solutions.
 Performs leak testing in accordance with the ¼

endoscope and leak-testing equipment
manufacturers’ IFU and by
a) removing all port covers and function valves;
b) placing the endoscope in a loose configuration; ¼
4. c) pressurizing the endoscope to the recommended ¼

pressure;
d) manipulating all moving parts, including the ¼

elevator, and angulating the bending section of
the distal end;
e) actuating video switches; ¼
f) Maintaining pressure and inspection for a ¼

minimum of 30 seconds.
 When an endoscope fails a leak test, removes it from ¼

service and sends for repair or replacement per
facility policy and procedure.
5. Manual Cleaning:
 External and internal cleaning ¼

(Enzymatic detergent solution)
 Brushing ¼
 Rinse with water to remove detergent ¼
 Dry the scope in clean cloth ¼
Endoscope Disinfecting
6. 1. For Manual disinfecting: 2
¼
a. Immerses the endoscope in disinfectant
b. Place all valves, removable parts, and any reusable ¼

brushes in disinfectant
c. Covers basin with tightly fitting lid ¼
d. Checks instructions for the correct immersion time ¼
e. When immersion is complete, purges channels with ¼

air to remove the disinfectant
Page 18 of 19
f. Immerse the endoscope in Distilled water and rinse ¼
g. Use a sterile, lint-free cloth to thoroughly dry all ¼

external areas
h. Transfer immediately to storage area ¼
2. For Automated Endoscope Reprocessor: 2¾

a. Follows the manufacturer’s instructions to connect
the endoscope to the re-processor ¼
b. Places the valves and other removable parts ¼

including re-usable brushes in the re-processor, if
possible (otherwise parts must be manually high-
level disinfected)
c. Attaches channel cleaning connectors ¼
d. For ERCP endoscopes, the elevator wire ¼
e. channel must be accessed manually ¼
f. Follows manufacturer’s instructions for the high- ¼

level disinfectant
g. Sets the machine for the recommended time ¼
h. Use a sterile, lint-free cloth to thoroughly dry all ¼

external areas
i. Transfer immediately to storage area ¼
 After both Procedure (Manual disinfection or

Automated Endoscope Reprocessor):
a. Removes personal protective gear. ¼
b. Washes hands before leaving reprocessing ¼

room.
Storage 1½
7. a. Hangs flexible endoscopes vertically in a well- ¼

ventilated area.
b. Stores endoscope in a protected manner. (Do not ¼

store in case)
c. Remove water resistant cap if used. ¼
d. Attach venting cap for storage if needed. ¼
e. Stores removable parts separately. (i.e. air/water & ¼

suction buttons, biopsy caps, water-resistant caps).
f. Confirm that the endoscope is stored in the ¼

Endoscope Storage Cabinets for no longer than the
validated time stated by the ESC manufacturer.
Page 19 of 19
Quality and monitoring 1¼
8.  Documentation:
a. Procedure of endoscopy to be recorded in
patient’s notes. ¼
b. The endoscope serial number is documented in ¼

the patient’s notes.
c. Each reprocessing is recorded manually or ¼

electronically, including the name of the person.
 Availability of tracking system:

a. Tracking System for the process is documented
in the electronic documentation system to make ¼
sure each reprocessing step was completed,
resulting in patient-ready endoscopes (Tracking
for process not the procedure)
 Availability of endoscopes cleaning IFUs:

d. An Instruction for Use according to company
manufactures is available. ¼
Total 14.5
Name and Signature of Auditor: _________________________
Name and Signature of Staff: ___________________________
Appendix 5: Example of Single –Room decontamination unit with two doors:
Page 20 of 19
Page 21 of 19
Appendix 6: Example of Single –Room decontamination unit with one door:
Page 22 of 19

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ANH/IC&CSSD/POL/07/Vers.

Institution Name: Al- Nahdha Hospital

Document Title: Endoscopy Decontamination Policy

Name Title Institution Date Signature

Written by Aziza Al-Maashari Infection Al- Nahdha January

Reviewed by Nada Al-Siyabi HOD infection Al- Nahdha January

Dr. Rasha Assistant Director Al- Nahdha January

Department Patient Safety

HCW Health Care Workers

EWD Endoscopy Washer Disinfector

Endoscopy Decontamination Policy

Effective cleaning and disinfection of endoscopes between clinical procedures is essential

5.1 Infection Control Measures

5.1.1 Disinfection and sterilization of medical equipment.

5.2.1 Pre cleaning at bedside.

5.3 Design of decontamination area:

5.3.1 Physical Separation between clean and dirty area/activities.

5.4 Water quality monitoring:

5.4.1 Water hardness:

5.5 Procedure of decontamination:

5.5.1 Flexible endoscopes:

Step or procedure Important points to look in it. Rational

detergent). The use of potable tap

 Transports the flexible endoscope

covered container as soon as

5.5.2 Rigid endoscope:

5.5.3 Quality monitoring and validation:

Sr. No Measures Frequency Responsibility

1. Documentation: With each -The doctor

and collect the liquid in a sterile container.

6. Document History and Version Control

Document History and Version Control

Version Description of Amendment Author Review

01 Initial Release Aziza Al-Maashari Jan/2019

Written by Reviewed by Approved by

Aziza Al-Maashari Dr. Nada Al-Siyabi Hospital Director

Instruction manual of Karl Storz-Endoscope

(Flexible Scope/Rigid Scope/Video-Rhino-

World Health Organization. Decontamination and 2016

Guideline Summary: Processing Flexible 2016

Health Facilities Scotland and Health Protection

Public Health Agency of Canada, INFECTION 2010

Health Technical Memorandum 01-06: March 2016,

Society of Gastroenterology Nurses and 2012

U. Beilenhoff1, C. S. Neumann2, J. F. Rey3, H. 2007

Guidelines Committee, ESGE–ESGENA

U. Beilenhoff1, C. S. Neumann2, J. F. Rey3, H. 2008

World Gastroenterology Organisation/World

Appendix 1: algorithm for flexible endoscopy decontamination

Gently wipe the external Flush all other channels Transport in a

Manual leakage test

All reprocessing steps are external

Manual Cleaning (Disinfection Process)

Transfer immediately to storage

Endoscopes marked “autoclave”

Autoclave at 134 degree C for three minutes at 2.0

Appendix 3: Flexible Endoscopes Procedure Audit Tool

2. Separation Dirty/Clean area: (1)

3. Water Quality Monitoring: (1)

according to the policy such as correct concentration of

6. Transportation policies are in place: (1)

7. Availability of written protocols: (1)

8. Presence of Audit tool: (1)

Name: ______ Date: _