POLICIES AND PROCEDURES MANUAL

INFECTION CONTROL IN GENERAL NURSING UNIT

DOCUMENT CONTROL REVISION NO. EFFECTIVITY DATE PAGE
NO. JANUARY O1, 2019 1 of 9
00 REVIEW DUE
IC-01-043 DECEMBER 31, 2020

I. OBJECTIVES
1. To protect endoscopy personnel from exposure to infection and prevent
transmission to other patients.
II. SCOPE

1. All clinical Staff within the Endoscopy Unit.

III. DEFINITION OF TERMS

None

IV. POLICY
1. The personnel involved in the Endoscopy Unit shall understand infection control
activities that may influence or decrease risk of infection transmission to themselves
and to patients in Endoscopy Unit.

V. PROCEDURES
1. Personnel
1.1 All healthcare personnel in the endoscopy suite should be trained in and
adhere to standard infection control recommendations (e.g. Standard
Precaution), including those to protect both patients and healthcare
workers.

1.2 The personnel should understand the risk of infection with agents such
as mycobacterium tuberculosis, HBV, HCV, HIV, herpes simplex and enteric
pathogens. The infected cases should be placed last in the list.

1.3 The personnel should understand that a patient’s infectious status may
be unknown at the time, of procedures hence the same precautions should
be applied to all patients.

1.4 Personnel should perform hand hygiene thoroughly before and after
procedure.

1.5 Skin disinfecting agent (Chlorhexidine) or Alcohol hand rub should be

used prior to any invasive procedures.

2. Reprocessing of Endoscopes

2.1 Endoscope disinfection or sterilization with a liquid chemical sterilant

involves five steps after leak testing:
Prepared by: Reviewed by: Conforme: Approved by:

JAN MARVIN M. PALIJO, MSN, RN GINA M. GARCIA, MD JM PALIJO MSN,RN/ R. RAYOS DEL SOL, MD NEIL ANDREW S.J. DE LUMEN, MD

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

 POLICIES AND PROCEDURES MANUAL
INFECTION CONTROL IN GENERAL NURSING UNIT
DOCUMENT CONTROL REVISION NO. EFFECTIVITY DATE PAGE
NO. JANUARY O1, 2019 2 of 9
00 REVIEW DUE
IC-01-043 DECEMBER 31, 2020

2.1.1 Clean: mechanically clean internal and external surfaces,

including brushing internal channels and flushing each internal
channel with water and a detergent or enzymatic cleaners (leak
testing is recommended for endoscopes before immersion).

2.1.2 Disinfect: immerse endoscope in high level disinfectant and

perfuse (eliminates air pockets and ensures contact of the germicide
with the internal channels) disinfectant into all accessible channels,
such as the suction/ biopsy channel and air/water channel and
expose for a time recommended for specific products.

2.1.3 Rinse: rinse the endoscope and all channels with sterile water,
filtered water or tap water (e.g. high quality potable water that
meets federal clean water standards at the point of use).

2.1.4 Dry: rinse the insertion tube and inner channels with alcohol
and dry with forced air after disinfection and before storage.

2.1.5 Store: store the endoscope in a vertical manner position to

prevent recontamination and promotes drying. Drying the
endoscope is essential to greatly reduce the chance of
recontamination of the endoscope by microorganism’s that can be
present in the rinse water

2.2 The suggestion to use only sterile water tor filtered water is not
consistent with published guidelines that allow tap water with an alcohol
rinse and forced air drying. In addition, no evidence of disease transmission
has been found when a tap water rinse is followed by an alcohol rinse and
forced air drying.

2.3 In addition to the endoscope reprocessing steps, a protocol should be

developed that ensures the user knows whether an endoscope has been
appropriately cleaned and disinfected. When users leave endoscopes on
movable carts, confusion can result about whether the endoscope has been
processed.

2.4 Infection control professionals should ensure the institutional policies

are consistent with national guidelines and conduct infection control rounds
periodically in areas where endoscopes are reprocessed to ensure policy
compliance.

Prepared by: Reviewed by: Conforme: Approved by:

JAN MARVIN M. PALIJO, MSN, RN GINA M. GARCIA, MD JM PALIJO MSN,RN/ R. RAYOS DEL SOL, MD NEIL ANDREW S.J. DE LUMEN, MD

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

 POLICIES AND PROCEDURES MANUAL
INFECTION CONTROL IN GENERAL NURSING UNIT
DOCUMENT CONTROL REVISION NO. EFFECTIVITY DATE PAGE
NO. JANUARY O1, 2019 3 of 9
00 REVIEW DUE
IC-01-043 DECEMBER 31, 2020

3. Laparoscopes and Arthroscopes

3.1 Laparoscope and Arthroscopies and other scopes that enter normally
sterile tissue should be sterilized before each use, if this is not feasible, they
should receive at least high level disinfection.

4. Recommendations for reprocessing Flexible Gastrointestinal Endoscopes

4.1 Before disconnecting the scope from the machine, take a secure hold of
the endoscope and wipe down the entire length of the insertion tube with
gauze soaked with enzymatic solution several times. Place the distal end of
the scope into a container with water and enzymatic solution. Suck through
suction channel by pressing the suction valve for at least 5 seconds. Change
the air/ water valve to blue cleaning adaptor flush with water and blow air
for at least 5-10 seconds.

4.2 Turn off the machine; remove the suction tubing and water bottle.

4.3 Replace video protector cap before disconnecting the scope from the
machine. Remove all the valves and clean separately with enzymatic
detergent and water.

4.4 Perform leakage test before submerging the entire scope to water with
detergent. If regularities or continuous bubbling observed, submersion of
the scope to water is prohibited. Send the scope immediately for repair.

4.5 Use the port manufacturer recommended cleaning brush to clean the
biopsy and suction port opening and carefully clean the distal end of the
scope to remove all organic, blood tissues and other residues.

4.6 Pass the channel cleaning thru:

4.6.1 Biopsy port and down the insertion tube.

4.6.2 Suction port and down the insertion tube.

4.6.3 Suction port and down the umbilical cord.

4.6.4 Clean the brush head time it emerges from the endoscope.

4.7 Completely immerse endoscope, valves and other accessories

into water with enzymatic solution. Irrigate channels.

Prepared by: Reviewed by: Conforme: Approved by:

JAN MARVIN M. PALIJO, MSN, RN GINA M. GARCIA, MD JM PALIJO MSN,RN/ R. RAYOS DEL SOL, MD NEIL ANDREW S.J. DE LUMEN, MD

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

 POLICIES AND PROCEDURES MANUAL
INFECTION CONTROL IN GENERAL NURSING UNIT
DOCUMENT CONTROL REVISION NO. EFFECTIVITY DATE PAGE
NO. JANUARY O1, 2019 4 of 9
00 REVIEW DUE
IC-01-043 DECEMBER 31, 2020

4.8 Clean biopsy forceps used. Valves and other accessories. Brush
tip gently to remove any debris.

4.9 Reusable endoscopic accessories (e.g., biopsy forceps or other

cutting instruments) that break the mucosal barrier should be
mechanically cleaned and then sterilized between each patient use
(high level disinfection is not appropriate).

4.10 Ultrasonic cleaning of reusable endoscopic accessories and

endoscope components may be used to remove soiled and organic
material from hard to clean areas.

4.11 Use a high level disinfectant/sterilant cleared by the FDA

recommended by endoscope Manufacturers Company to avoid
functional damage

4.12 Place the endoscopes and other accessories into an Automatic

Endoscope Re processor. Connect appropriate washing connectors
to the scope. Ensure the adequate irrigation and contact time.

4.13 After cleaning and disinfection is complete, rinse the insertion

tube and inner channels with alcohol and dry with forced air before
storage. Final drying is essential to reduce the possibility of
recontamination of the endoscope with waterborne
microorganisms.

4.14 When storing the endoscope, hang it in a vertical position to

facilitate drying. It should be stored in a manner that will protect the
endoscope from contamination.

4.15 Maintain a log indicating for each procedure the patients name
and medical record number, the procedure, the endoscopist, and
the serial number or other identifier of the endoscope to assist in
outbreak investigation.

4.16 Perform routine testing of the liquid sterilant/high level

disinfectant to ensure minimal effective concentration (MEC) of the
active ingredient. Check the solution at the beginning of each day
and document the result. If the chemical indicator shoes that the
concentration is less than the MEC, the solution should be
discarded.

Prepared by: Reviewed by: Conforme: Approved by:

JAN MARVIN M. PALIJO, MSN, RN GINA M. GARCIA, MD JM PALIJO MSN,RN/ R. RAYOS DEL SOL, MD NEIL ANDREW S.J. DE LUMEN, MD

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

 POLICIES AND PROCEDURES MANUAL
INFECTION CONTROL IN GENERAL NURSING UNIT
DOCUMENT CONTROL REVISION NO. EFFECTIVITY DATE PAGE
NO. JANUARY O1, 2019 5 of 9
00 REVIEW DUE
IC-01-043 DECEMBER 31, 2020

4.17 Facilities where the endoscopes are used and disinfectant

should be designed to provide a safe environment of healthcare
workers and patients.

4.18 All personnel using chemicals should be educated about the

biological and chemical hazards present while performing
procedures the use disinfectants.

4.19 Personal protective equipment (gloves, gowns, eyewear,

respiratory protection devices,) should be readily available and
should be used as appropriate to protect workers from exposure to
chemicals, blood, or other potentially infectious material.

4.20 The utility of routine environmental microbiologic testing of

endoscopes for quality assurance has not been established.

4.21 In the setting of an outbreak caused by a suspected infectious

or chemical etiology, the environmental sampling should be
performed according to standard outbreak investigation.

4.22 Endoscopy related infections should be reported to Infection

Control Team.

4.23 All endoscopes received for reprocessing must have the

following information on the endoscope nursing record sheet:

 Patient name
 Medical record
 Procedure
 Identifier number of endoscope used (serial number).

5. Additional Precautions During Bronchoscope

5.1 The following control measures should be implemented to

prevent transmission of M. tuberculosis, severe acute respiratory
syndrome (SARS), or other organisms potentially transmitted via
airborne droplet nuclei:

5.1.1 Appropriate hand hygiene should be performed before

and after all procedures.

5.1.2 Patients undergoing aerosol generating procedures,

including bronchoscopy, should be screened for symptoms
Prepared by: Reviewed by: Conforme: Approved by:

JAN MARVIN M. PALIJO, MSN, RN GINA M. GARCIA, MD JM PALIJO MSN,RN/ R. RAYOS DEL SOL, MD NEIL ANDREW S.J. DE LUMEN, MD

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

 POLICIES AND PROCEDURES MANUAL
INFECTION CONTROL IN GENERAL NURSING UNIT
DOCUMENT CONTROL REVISION NO. EFFECTIVITY DATE PAGE
NO. JANUARY O1, 2019 6 of 9
00 REVIEW DUE
IC-01-043 DECEMBER 31, 2020

suggestive of tuberculosis, SARS, or other infections capable

of being transmitted via airborne droplet nuclei. If patients
are suspected of having these conditions, the following
measures should be implemented:

5.1.2.1 Bronchoscopy should not be performed

unless necessary.

5.1.2.2 If medically necessary, bronchoscopy should

only performed in a room that meets the ventilation
requirements for airborne infection isolation
(negative directional air flow, a minimum of 12 air
exchange per hour and direct exhaust to the outside
more than 25 feet from an air intake or discharged
through a high efficiency particular air filtration
system.

5.1.2.3 Healthcare workers should wear appropriate

personal protective equipment.

5.1.2.4 After the procedure patient may continue to

cough and pose additional risk, therefore, airborne
precautions should be maintained.

5.1.2.5 The room should not be used for another

patient until adequate time has elapsed for
potential airborne contaminants to be removed.

5.1.2.6 The endoscope and accessories should be

cleaned and reprocessed as per the manufacturer’s
recommendations.

6. Disposable or Reusable Endoscopic Accessories

6.1 Endoscopic accessories used to biopsy, brush, or cut tissues

should be cleaned and undergo steam sterilization or, if disposable,
discard after use.

7. Adverse Event Reporting

7.1 Serious adverse events (including outbreak/infections)

associated with an endoscope, endoscope accessory or disinfectant/
sterilant should be reported to Infection Control Team.
Prepared by: Reviewed by: Conforme: Approved by:

JAN MARVIN M. PALIJO, MSN, RN GINA M. GARCIA, MD JM PALIJO MSN,RN/ R. RAYOS DEL SOL, MD NEIL ANDREW S.J. DE LUMEN, MD

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

 POLICIES AND PROCEDURES MANUAL
INFECTION CONTROL IN GENERAL NURSING UNIT
DOCUMENT CONTROL REVISION NO. EFFECTIVITY DATE PAGE
NO. JANUARY O1, 2019 7 of 9
00 REVIEW DUE
IC-01-043 DECEMBER 31, 2020

V. REFERENCES:

1. CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2012.

2. APIC 2014.

VI. SIGN-OFF AND REVISION HISTORY

Prepared by: Reviewed by: Conforme: Approved by:

JAN MARVIN M. PALIJO, MSN, RN GINA M. GARCIA, MD JM PALIJO MSN,RN/ R. RAYOS DEL SOL, MD NEIL ANDREW S.J. DE LUMEN, MD

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

 POLICIES AND PROCEDURES MANUAL
INFECTION CONTROL IN GENERAL NURSING UNIT
DOCUMENT CONTROL REVISION NO. EFFECTIVITY DATE PAGE
NO. JANUARY O1, 2019 8 of 9
00 REVIEW DUE
IC-01-043 DECEMBER 31, 2020

Owner

INFECTION CONTROL

Initiator

JAN MARVIN M. PALIJO, MSN, RN – CHIEF NURSING OFFICER

Reviewer

GINA M. GARCIA, MD – CHAIRMAN, DEPARTMENT OF MEDICINE

Approvals:

ARGYLL T. ARCIGAL, MD
CHIEF OF CLINICS

CHERRY PINK D. ORDINAL, MD

QMD Head

RICO M. RAYOS DEL SOL, MD

Chief Medical Officer

Prepared by: Reviewed by: Conforme: Approved by:

JAN MARVIN M. PALIJO, MSN, RN GINA M. GARCIA, MD JM PALIJO MSN,RN/ R. RAYOS DEL SOL, MD NEIL ANDREW S.J. DE LUMEN, MD

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

 POLICIES AND PROCEDURES MANUAL
INFECTION CONTROL IN GENERAL NURSING UNIT
DOCUMENT CONTROL REVISION NO. EFFECTIVITY DATE PAGE
NO. JANUARY O1, 2019 9 of 9
00 REVIEW DUE
IC-01-043 DECEMBER 31, 2020

NEIL ANDREW S.J. DE LUMEN, MD

President

Revision History

Revision Effectivity Review Prepared/Revise

Details of Revision
No. Date Due d by

Prepared by: Reviewed by: Conforme: Approved by:

JAN MARVIN M. PALIJO, MSN, RN GINA M. GARCIA, MD JM PALIJO MSN,RN/ R. RAYOS DEL SOL, MD NEIL ANDREW S.J. DE LUMEN, MD

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT