reprocessing, a comparative review of organizational guidelines, and a guide for endoscopy units and regulatory agencies. You will be able to submit questions and comments throughout the event via the Q&A box. A roundtable discussion with audience Q&A will be held at the conclusion of Dr. Tong's presentation. My name is Eden Essex, and I will be the announcer for this session. The objectives for this session are to, first, review the multiple reprocessing guidelines that exist, to provide endoscopy units with specific recommendations on how to safely reprocess endoscopes and comply with governmental regulations, specifically looking at alignment and variance among the guidelines. Then we will discuss the imperative for endoscopy units to review their infection control policies and reconcile any differences between the reprocessing recommendations so that contradictory policies are not developed or followed. A recording of tonight's session will populate your G.I. LEAP account when it is available next week, so you can review the content anew or watch it with others. Now it is my pleasure to introduce our presenter, Dr. Pushpak Tong. Dr. Tong is an associate professor in the Division of Digestive Disease and Nutrition and the Director of Ambulatory Surgery at the University of South Florida in Tampa. He is the lead author of the ASG paper that we will be discussing. I will now hand the proverbial floor over to Dr. Tong. All right. Thank you, Eden, for that wonderful introduction. Thank you all for coming to listen today. I hope this talk is useful. All right. Now I'm going to go ahead and share my screen. All right. So as Eden mentioned, today our topic is going to be making sense of the multiple reprocessing guidelines, and hopefully we'll be able to help you put together all those different guidelines that are out there. I have no disclosures. So again, the role of reprocessing guidelines is obviously to ensure patient safety and minimize infection risk. It's also used for initial certification and maintenance of accreditation. CMS actually mandates that a formal infection control program be put in place for the surgery centers. And that program has to be based on a nationally recognized infection control guideline. No infection control guideline is specifically endorsed by CMS. And so endoscopy units must cite references from various specialty societies when discussing with regulators. There is significant variability amongst reprocessing guidelines. Obviously, multiple guidelines are exclusive for endoscope reprocessing, and they're typically comprised of physicians, nurses, infection control agents, and government agencies. There does remain some heterogeneity in which reprocessing recommendations are followed across the country, but units do have the latitude to adopt policies that are most suitable to their setting. It's important that units avoid getting penalized based on different guidelines. And so, you know, our goal today is really to sort of help sort those things out. As you can see, there are multiple organizations that have put out reprocessing guidelines. And in order to stay compliant with either your state or your federal regulation, it's important to be able to reconcile these guidelines so that your unit can maintain accreditation. So our aims today will be to review all major U.S. endoscope reprocessing guidelines. We'll examine the similarities and differences amongst various organizations and reconcile the recommendations made by those various organizations. Most importantly, this talk should help you improve communication between your unit and regulators that come. This talk is based on an important document that was put out by the ASGE Quality Assurance Committee, and you can see it in the June GIE issue. And today I'm also joined by Dr. Raman Muthuswamy and James Collins, who will also serve as the panel and are co-authors on this paper. Again, these are the core principles of infection control. These are all process points that your units are likely doing to help clean scopes, and we'll go through each of these one by one. So first, I'm going to focus on where guidelines tend to have areas of uniform consensus. And these are things that your unit really should be doing because there's significant agreement amongst guidelines. When it comes to staff training and competency, endoscopy units should have a written endoscope reprocessing policy, and all staff must undergo reprocessing training. Competency should be verified and documented. This can be audited by direct observation, and it's important that trainers are also competent to reprocess scopes. There are some organizations that also recommend completing a certification exam. For endoscopy unit layout, reprocessing should not be performed in the patient care area and instead in a room that's physically separate from the procedure room. In this diagram from the AORN, you can see that units should use a one-way pattern of flow from the contaminated to the clean area, regardless of whether you have a one-room or two-room design. The first step typically begins with pre-cleaning. This is usually done immediately after a procedure is completed. A cleaning solution should be used for both the exterior and interior of the endoscope, and that solution should then be aspirated through the channel of the endoscope. The scope should then be transported in a separate, closed, and clearly labeled container, and once leak testing is performed, if it fails, that scope should be removed and repaired. These are the steps of manual cleaning. So you must detach all devices, submerge the endoscope in an enzymatic cleaning solution, brush all channels until clear of debris, then flush those channels with an enzymatic cleaning solution, and rinse the endoscope. Here I'm going to show a video of how this process is done at Tampa General. We log all our inpatient and doctor information so we know what scope and doctor it belongs to. So when we take our scope, we take it to our leak test machine to make sure there's not any leaks or punctures inside the scope so it can be used on the next patient. From there, we take the scope, we will put it in the sink, and we will put it in our sink that we put six gallons of water. So we put two squirts of detergent here so that helps it keep that detergent used to keep that scope clean. We'll take the brush. Now I wanted to stop the video here for one instance. As you can see here, we have wire baskets above the sink. Now this is not something initially that was noted by our team but was noted by some people that were actually helping us. And one of the problems with this actually is that these baskets really need to be a solid container and not a wire container because they're above a splash zone above the sink despite the fact that these are packaged brushes. So the reason I stopped it here is I wanted to use it as a learning point in that it's really important to comb through the details of a reprocessing guideline, whichever one you're following, so that you can make the changes that are necessary. Now I will tell you I spoke to our nurse manager about this issue and this has since been replaced actually with solid containers. These brushes here and we will put it through these two channels. If you look over here through these two channels and they come out through this port and through here. And then from there we also get a sponge and clean the whole scope after. All right so that gives you an idea of the the manual cleaning process. Now again it should commence once pre-cleaning is finished. It's important that the manufacturer's instructions for use are followed for manual cleaning with respect to both brushes and the enzymatic cleaning solution. The solution should not be reused during reprocessing and if there is a time delay that occurs again the manufacturer's delayed cleaning protocol should be adhered to. For duodenoscopes it's very important to clean and brush the elevator mechanism as we know that that may be a nidus of infection. The next step is typically high level disinfection. It's critical that high level disinfection be performed as a component of endoscope reprocessing and all guidelines agree on that. The high level disinfection solution should also be tested for minimum effective concentration. Here Miguel is going to show you how we do high level disinfection in our unit. And then from there the person on this side will grab the scope and attach it to the specified block to the actual to the specified scope. And when we use it it cleans out through all the channels again and then from there it takes about 30 to 40 minutes depending on the scope to finish. So when we get to the elevator and we're ready to take out the scope What actually cleans the scope is, if you look right here, is alcohol, right here, and the detergent. This is Intercept and the alcohol that we have here, and then we go to our RapidSide PA Part A and B. And these two work in conjunction to clean the scope. So to check the sterility of the RapidSide to make sure that it's working correctly, And so this gives you an idea of how high-level disinfection is performed, as well as checking for the minimal effective concentration. The next step is rinsing and drying, rinsing endoscopes and flushing channels to remove the disinfectant solution. So that air drying is recommended after high-level disinfection and rinsing. In terms of endoscope storage, endoscopes, again, should be stored per manufacturer's instructions for use, and cabinets should be sufficient dimensions to allow secure storage. If they are stored vertically, they should hang freely and not touch each other or the bottom of the cabinet. For endoscope accessory storage, they should be removed before storage. And again, this includes air, water valves, suction valves, and caps. For verification of reprocessing, it is important that units develop a program for cleaning verification to really determine if adequate cleaning is being done for the scopes. And units should maintain documentation of that reprocessing. For reprocessing of accessories, semi-critical devices, again, the air water valve should undergo a high-level disinfection after each use, but reusable water bottles and tubing can undergo daily high-level disinfection. For maintenance of endoscopes, manufacturer's instructions for use, again, should be followed and should consider maintaining records of preventative maintenance. Most organizations actually do not have guidelines on loaner devices. For endoscopy unit leadership, again, very important that we have a multidisciplinary approach. The following table is taken from our paper, and it shows all the areas of consensus among endoscope reprocessing guidelines. So you can look to our paper for specific details. And now I'm going to discuss where there are some areas of minor variation amongst the guidelines. For staff training and competency, there's no consensus on the content of training and how exactly to verify competency, whether by direct observation or certification exam. How often the evaluations need to be performed or when they need to be performed, again, varies on which organizational guidelines you are following. For pre-cleaning, there's no consensus on the volume of solution that must be aspirated. And again, only the ASGE specifically recommends pre-cleaning of duodenoscopes specifically in the elevator area. And then again, there's no consensus on the acceptable tie interval in which pre-cleaning should be performed. For manual cleaning, some guidelines recommend using a single-use brush, while others favor a reusable brush for cleaning. And again, the type and quality of rinsing water that's recommended at the end of manual cleaning, again, varies based on organizational guidelines. Borescopes, again, these are instruments that can be inserted through the channel of a scope, specifically looking for any kind of damage, water droplets, or fluid. There is variation in the frequency and indications for borescope use. And again, we aren't certain exactly what to do with the findings of, you know, using a borescope. So currently, no guideline specifically recommends their use at this time. For high-level disinfection, whether or not the solution needs to be FDA cleared, again, there's variation amongst guidelines. Whether or not you need to do manual or an automated endoscope reprocessor, there's variation. And then importantly, the timing and frequency of testing the disinfected solution for minimum effective concentration, again, varies based on the guidelines. In terms of how to discard the solution after high-level disinfection, again, there is significant variation. There's no consensus on, again, which devices and accessories need to be sterilized. When it comes to duodenoscopes, the FDA does recommend a transition to duodenoscopes with innovative designs. And those are things that you may have now heard about or even seen in your unit, which are the disposable duodenoscopes or the new scopes with a detachable end or disposable end. The ASGE multi-society reprocessing guidelines has shown that repeat HLD has no additional benefit compared to single HLD for duodenoscopes. They also did not recommend ethylene oxide sterilization to reduce bacterial contamination. For rinsing and drying, again, the quality of water used in rinsing and flushing after HLD, there's significant variation. And then whether or not to use alcohol within the drying process, again, alcohol does enhance water purging, it facilitates drying, and it can be antimicrobial, but again, its use depends. And actually, some of the European guidelines do not recommend its use where prion disease is endemic. For drying, continuous and forced air is typically delivered or by air purge cabinets. Again, the quality and type of air that's used during drying varies. And there is no specific minimum drying time, although the ASGE does recommend continuous forced air for at least 10 minutes. And again, there's no consensus on the amount of drying needed if a scope is returned for reuse immediately. For endoscope storage, the type of cabinet varies. Whether or not scopes need to be stored vertically or horizontal, again, there's no agreement. And then importantly, the storage interval prior to needing to reprocess the scope again, or what is known as hang time, that's how long a scope is allowed to hang in a cabinet before it needs to actually be reprocessed again if it hasn't been used. Again, there's no data on this, while the SG&A does say to consider seven days. For endoscope accessory storage, whether or not they need to be stored with or separate from the endoscope varies. And then for verification of reprocessing, this is typically done through microbiological surveillance. This serves as an indicator of inadequate reprocessing or defective devices. Again, there's no recommendation for routine endoscope microbiological surveillance, but it should be considered an infectious outbreak or as a quality assurance measure. ATP testing is not supported by the FDA or regulatory agency. And again, while it's important to do microbiological surveillance, there's really no guidance on the modalities, frequency, or the location for endoscope culturing and really no standard on what defines a positive culture. All of that being said, if you are performing surveillance at your unit and you do get a positive culture, it's important to quarantine that scope. For verification of reprocessing, again, the frequency and modality of testing, what benchmarks are needed and readiness for use, and the documentation of what is necessary, again, varies. For documentation of reprocessing, most guidelines do say patient name, MRN, and endoscope identifier is important, with some organizations listing some other aspects that can be recorded during the reprocessing. And again, for endoscopy unit leadership, the composition of the team, the roles and responsibilities of the team may vary, and then various duties of the team during an outbreak may vary based on which guidelines you're following. So for future directions, again, several aspects of reprocessing still require further study. For example, how and when should HLD solutions be checked for minimal effective concentration? What is the optimal scope hang time? And what are best ways to verify endoscope reprocessing? These, I think, still need further study. It is important for national organizations to work together and further solidify areas of consensus. And of course, organizations and regulators should try to collaborate on best practice guidelines. Some key takeaways today are there are obviously several areas of agreement amongst guidelines. It's important for units to implement those areas of consensus as it will help prepare your unit for accreditation. Some guidelines do have more granularity on various aspects of scope reprocessing. So it's important to read those in detail. And again, you can use our documents as sort of a risk assessment tool prior to a site survey. So these are my references and thank you for taking the time today to listen. Thank you, Dr. Tonk. Now joining Dr. Tonk for further discussion and to address your questions, we welcome Dr. Raman Muthusamy and Jim Collins. Dr. Raman Muthusamy is currently a professor of clinical medicine at the David Geffen School of Medicine at the University of California, Los Angeles, and he is the medical director of endoscopy for UCLA Health. Jim Collins is at the Cleveland Clinic as the quality assurance and accreditation nurse. He is a member of the Amy work group that revised the ST-91 endoscope reprocessing standard. Jim has been active at the national and local levels of the Society of Gastroenterology Nurses and Associates for many years. We are now ready to take your questions. And so please submit them and any comments you have in the Q&A box, please, please be sure to use the Q&A box and not the chat box to submit questions or comments that will keep us organized. We did get a question about the slides you already have in G.I. Leap. If you registered for this event, you have a G.I. Leap account and in there is already a copy of the slide deck. So you can immediately log into G.I. Leap at learn.asge.org. Once you're logged in, you'll see a module for this quote unquote course and you can already download the slide deck from there. And then once the recording is ready, we'll go ahead and just automatically populate that in your account. So our first question is, do you think scope sterilization is coming? So why don't we go around the table with that? Maybe we'll start with Jim. What do you think? Do you think scope sterilization is coming? There certainly has been sufficient conversations about the sterilization of endoscopes. However, the technology to provide sterilization of endoscopes still needs to evolve where it's readily able to be performed in our AECs, in our ASCs. With that being said, sure, it could happen. But when it will happen depends on the sterilization technique catching up with the task at hand. So I still think it's a pretty in the near distance, but it'll probably not come before I retire. So. Sami, maybe as you address this question, you can talk a little bit about single use as well, if you wouldn't mind. Yeah, I mean, I think that the issue is if we are going to sterilization, where do we need to do it for? So I think it may not be for all scopes. Obviously the area that we seem to have the most challenges with have been with duodenoscopes and with the elevator mechanisms and some of those scopes. And the other issue is should we sterilize scopes that are perhaps going to be used in areas outside of the traditional GI lumen. We're increasingly doing third space procedures. And so perhaps maybe doing that. I completely agree with Jim that, you know, I think we're all would be supportive of it if it was practical. I mean, we need a low temperature solution that's economical and that practices can, you know, sort of manage. I know that that's being worked on by several of the reusable device manufacturers. So I do think we are going to start seeing some sterilization. I think it makes the most sense, though, for duodenoscopes and perhaps scopes used in complex third space procedures. I think for right now, there's not a lot of evidence to suggest that HLD is not sufficient for most of the diagnostic procedures we do today. Thank you. Dr. Tonk, any additional comments on that? Yeah, I mean, I agree with Dr. Mitsutami and Jim. I will tell you in our unit, we were at some point doing ethylene oxide sterilization of the duodenoscopes. And, you know, once more data came out that high level disinfection was sufficient, we went away from it. And a lot of that had to do with the time constraints and the fact that we would have to send these scopes to a different site, sometimes off site, and we would not be able to get the scope back for 24, sometimes even longer hours than that. And so I think the cumbersome process and the time really took us away from ethylene oxide sterilization. And, of course, the data is showing that we didn't necessarily need to have to do it. But, you know, as Dr. Mitsutami is saying, is, you know, if there are solutions that are easier to use, then it may be relevant to, I think, specific scopes, but obviously not all scopes. Yeah, and Eden, I'm sorry you asked me to speak about single use devices. And I think, of course, we currently have single use duodenoscopes, there may be additional single use type scopes that are going to be coming in the near future. I think that they fill the need. Right now we don't have low temperature sterilization, and so in those cases where we need it, it'll be interesting to see what their role is when we actually do have low temperature sterilization. Perhaps maybe it'll be something particularly useful for sites that do these kinds of procedures that don't readily have the reprocessing facilities available, and it may make just sort of sense to expand our site of service by having some single use options. So I suspect that all of these things will start playing a partial role in the market in the years to come. Thank you. I'll start with this next one with Jim. This person says, hello, we're currently in the window for our surveys. So we held a mock survey at our endoscopy center. On the mock survey, the surveyor said it is a requirement to channel check or microbiological surveillance. Am I correct that it is not a requirement of ASG or AIME to do that surveillance? Yeah, your interpretation is correct. That's a very good question. And there is not the consensus among guidelines to perform cleaning verification upon every endoscope. Your interpretation is correct. And, you know, there are surveyors, you know, often have some personal thoughts on guidelines that may be shared there. There are some states that do have mandates where certain guidelines need to be followed. But for the vast majority, the cleaning verification is an optional task to be done. It can enhance your practice and can help identify problem areas. But it's not a requirement yet. The new AIME document suggests that cleaning verification be performed with all high risk endoscopes, that being in our GI labs, the duodenoscopes, of course, and the linear echo endoscopes that also have an elevator and also bronchoscopes, if you do bronchs in your unit. And our next question is, and I'll direct this to you, Dr. Tonk, first. Is there a specific set of guidelines you recommend over another, like ARN? And if so, why? And then maybe we'll just go around to all of you and you can share the guidelines maybe that you've adopted for your units. Yeah, that's a good question. I don't know that we follow one specific guideline. I will tell you in our unit, we typically use the ASG multi reprocessing guidelines from 2021. We've also been using the AIME guidelines, not the newly revised ones that just came out, but before that, the AIME guidelines as well. But I think some of that is also unit specific in terms of which scopes you're using, which scopes you're reprocessing. But those are the ones that we typically use. Dr. Vatsasamy, any comments? Yeah. I mean, I think that this is an important point because, as Pushpak has very nicely demonstrated in this article, not all the people agree on the same things and you can't be a member of all religions at once, so you kind of have to pick which one you're part of. And I think that for endoscopy units, it probably makes sense to use an endoscopy unit-based guideline. Obviously, my institution also uses the ASGE multi-society reprocessing guideline, and certainly we should because I was an author on that. I think we should follow, I guess, the things that we believe we authored. But in all seriousness, I think that makes the most sense because some of these other societies may have things that are more pertinent to an OR as opposed to an endoscopy unit and may not be as practical. So I think that it is important that you pick one and then you follow that and justify that. But again, there will be some things that are different among these, as this article really nicely highlights. And it's, I think, very important to specify to a surveyor which set of guidelines you are following. Bethany, have you experienced any institutional pushback on adopting, say, GI-specific guidelines versus maybe falling under OR? Yeah, I can take that one first. Obviously, we had an outbreak at my institution in 2015, which was fairly widely publicized. And at that time, we had plenty of surveyors come by. And one of the issues that we had was trying to get endoscopy-specific processes in place because we were under AORN guidelines because we are a subsidiary of operative services in my institution. And it was actually as part of that process and becoming part of the endoscopy unit recognition program that we transitioned to the ASG multi-society guidelines, which we currently follow to date. Any additional comments, Dr. Tonk, Jim? Well, I think units have to really read the documents that are available, read the guidelines. I think that's what the comparison paper clearly demonstrates is there are numerous guidelines. There is consensus for a lot of practices, but there's not total consensus. And our practices vary upon the nature of the procedures we do and the inventory of endoscopes that we have. So review the guidelines and choose the guideline that fits your practice and the type of services that you provide. And I think that that will help you greatly because when you do choose that, you need to be able to be fluent and articulate it correctly. And as Dr. Rahman stated that sometimes we pick a guideline because of the service that we fall under, and it just may not be the best guideline for what you do, for what your practice is. Yeah, I mean, I'll echo basically what both of them have said. You know, in our unit, as I mentioned, we were doing ethylene oxide sterilization before for duodenoscopes. And again, a lot of this was because our GI division falls under the operating room. And so they wanted to apply the operating room standards to all, you know, to the duodenoscopes and if not all endoscopes. And so, you know, I actually sat down with the infection control, I guess, representative from our hospital and kind of sent them the ASGE multi-society reprocessing guidelines, as well as some of the other ones, just showing that there was consensus that we didn't need to do this. And eventually over time, you know, they did sort of agree that we didn't need to do ethylene oxide sterilization. So I think it's just keeping an open communication channel between your infection control sort of champions at your hospital. It's important to know who they are, kind of let them know, you know, why you're following certain guidelines and why, you know, maybe OR guidelines don't necessarily apply to your unit, but then back that up with the appropriate guidelines. Thank you. So our next question is, how do you perform cleaning verification if not doing cultures or ATP? And I don't know if this is an opportunity to talk at all about boroscopes and any thoughts on boroscopes. So I think I'll just start with Dr. Muthuswamy. Is this a good place to talk about our thoughts on boroscopes? Yeah, I mean, this is one of my favorite questions and literally in every talk I do on this, I say this is the big challenge, right? How do you prove clean is clean? How do you prove a negative that there's no contamination? And as was pointed out here, you know, culture is not perfect either. We know there are many sites that have had outbreaks that were culture negative repeatedly on scopes. Culture is challenging and typically there's, as was outlined in the paper that Pushback just described, there's different protocols for culturing based on different, you know, the FDA versus CDC versus others, one person, two person, what constitutes a positive culture, a number of calling foreign units, what's a high risk organism? So it's very variable and even ATP testing, except for maybe perhaps documentation and manual cleaning is also variable. So I think that it's a real challenge leading to your specific question. You know, we've done some boroscope research at our institution. You definitely will find a lot of wear and tear. You'll find particularly instrument channels with scratches, peeling, depending on your term, discoloration. Some divots you'll see where it's interesting. We've actually looked with a boroscope and can see that brushes don't reach the full depth of the divot. And so perhaps maybe this is a potential mechanism for biofilm formation. I think the key question is at this point, we just don't know the significance of what we're looking at. So we see abnormalities, but what's the clinical implication of that? Is that really important? Is it not? How does that correlate to actual device damage or clinical outcomes? I think those are all the X factors we don't know. I will say this. Even if you don't have a boroscope, I would recommend, and Dr. Townka is an interventionist as well, that all of us who do cholangioscopy put cholangioscopes down our ERCP scopes. And I would argue that we should probably take two seconds, in addition to looking at the duct, to look at our channel's instrument channel as well. It may be equally important. So it is, and several of the sites that have had outbreak have subsequently found that they did have critical device deficiencies that were not made aware of. And so perhaps using things like boroscopes may better identify abnormalities. And maybe we just need to send our instruments in for sort of maintenance more frequently than we have been to catch these things. So those are some of my thoughts. And just a reminder for folks, you can go to learn.asge.org, and that is ASG's online learning platform. We refer to it as GI Leap. And once you log in, this is already set up as like a course within there, and you'll be able to download the slides from there. If you don't know how to log into GI Leap, it's the same username and password you use on ASGE. But if you're not sure, go ahead. I know a lot of you know me, Eden Essex. You can just email me directly or email quality at asge.org. That's quality at asge.org, and I'll help get you in there. GI Leap is really wonderful, and for those of you who are members, we have a lot of free content in there that I think would be of interest, especially for those of you who are EURP. Dr. Musasame mentioned the Endoscopy Unit Recognition Program. We have some content that is considered premium content, only available to you as an honoree unit, so I want to give a plug for that. I don't have any questions in queue right now, so please feel free to answer any questions or enter any questions that you might have. Is there any pearl, a little bit of wisdom that you want to offer to our audience that maybe we haven't covered today? Well, I think what I'd like to share is that reprocessing is really a house, a house that's built on a foundation of nine concurring steps, and each step is built upon the other, and they all need to be done effectively to come to a good outcome, and also that leadership, the unit leadership and oversight within the unit is imperative as well, and to visit the reprocessing room and to just monitor the flow and what goes on in that room. As we could tell by the film, it's a busy unit, and it's high action, and there's a lot going on there, so for managers to be aware of what's going on in their unit so they can keep the pulse of what's going on for, you know, our physician colleagues can't work without clean endoscopes, and all it does is back up the day when they're not cleaned, so I think those are the two things that I would encourage my colleagues to keep up on, and also to review the literature. There's more being written about endoscope reprocessing now than I think has ever been. 2015 really hit the mark of all types of research being done, so look at that research and see how that applies to your practice. And before we go to the doctors for their Pearl, give them another minute, just a quick question, and Jim, maybe we'll start with you so the doctors can think about their Pearl if they didn't have one ready. If you mix and match some recommendations, for example, you follow ASG overall but use APIC for water and alcohol, does that set you up for problems with the auditors? Well, it's okay to have a buffet, smorgasbord approach to your policies and procedure, as long as those are keenly noted in that policy and referenced, without being able to reference that, well, we do this according to ASGE, and to enhance our process, we do this from AORN. Then you lead the surveyor with kind of a fuzzy roadmap of what to follow, but by just like any good reference paper, you footnote those references from the guidelines, and then you have a good roadmap for your accreditation process. Okay, and on that question, do either of the doctors have any additional notes? Yeah, I think that that's exactly right, because they want, my experience with surveyors, and I'm probably not as experienced as some, but is that they want to know what your policies and procedures are, and do you do what you say you do, all right? And so if you've got your own set of policies and procedures that you've mixed and matched, doing what Jim said is fine, but again, you just have to make sure that you've got the references. The advantage of using, of course, one society or another's is that those societies have done the work, right, and they've sort of laid out what to do, and then you can just basically follow it. So I think it's easier to just pick one, but certainly if you're able to mix and match based on what you feel is right for your institution and document that, that'd be fine. I think they just want to make sure you're consistent with your policies. And Dr. Tonk, any thoughts on, additional thoughts on that? Or do you want to give us your pearl? Yeah, I guess I'll sort of just combine it. I mean, I think I sort of agree with everything, but I think one of the most important things, you know, especially coming out of this document is, you know, if you're picking areas where there is consensus, obviously there's safety in consensus. So, you know, we've outlined that for people, and I think those are areas where your units, it's an easy win, it's an easy thing your unit can do. In areas where there is some variation or where there's granularity, more granularity in one guideline than another, I think then it really sort of behooves you to pick which guideline you really think, you know, your unit should follow based on, you know, what practices, you know, you're having. And I think, as Raman mentioned, I think it's really important to just practice kind of what you're following, right? So, you know, if you're following a guideline, really read those guidelines, you know, know what's in them and kind of follow them. And I think, you know, you'll be okay. Okay, we got another hot topic question in here. So, it's about co-locating your device with accessories. So, you know, is it, what are the thoughts on keeping the same accessories and buttons with colonoscopes and endoscopes? Is it mandatory or is it recommended? So, Jim, you want to start us off on that one and then the doctors can fill in? Yeah, certainly. Well, again, that will take you to your practice as guided by the guidelines you decide to adhere your practice to. So, if you would follow the guideline that states that your removable accessories are married to the endoscope and remain with the endoscope throughout the cycle of that scope, then you need to have those devices readily available with that endoscope. If there's others that don't lend clear guidance that these removable devices need to be married to the endoscope and cohorted together for all eternity. So, that's a practice that the facility has to examine and take a look at what fits best into the operation of the unit. So, there hasn't been a consensus drawn on this yet. There's still guidelines that have differences. Any thoughts from the doctors on that issue of co-location? Again, I don't think there's any consensus on it. You know, the guidelines are almost split, you know, halfway whether or not you should or should not, you know, it's not like most do or most don't. So, I think, again, you know, as Jim mentioned, it really depends on which one you follow. And what about feasibility? Are any of you co-locating? Yeah, I mean, I think a lot of people are going to single-use buttons. And so, we tend to do a lot of that in my unit as well just to eliminate this issue. But I think, yeah, from a feasibility standpoint, I think it's pretty difficult to follow. Okay. And let's see. So, we have a person who says, if the buttons are steam sterilized, they will not be able to be kept with the specific endoscope. So, I think we would agree with that statement. Yeah, that's an excellent point. And the ability, there's a lot of facilities that I'm aware of that do sterilize their buttons just to be able to say, well, we've raised the bar, they're not high-level disinfected, they're sterilized. So, do we actually need to keep them married to an endoscope? Because it's, you can't, they're separated, they go out. So, you're offering them a higher level of care than the HLD, which makes it almost like a single-use valve then being utilized. And we have someone saying that that is the optimal treatment for those buttons. So, they certainly agree with that. So, if we have any other questions, go ahead and pop them in. I think we still, do we have a pearl from you, Dr. Muthulsami, that may just wrap us up today? Well, I mean, I think that it's important for you, I think going back to the issues that the document raises about unit leadership is to perhaps even just imagine, you know, should a situation arise, if you have an outbreak, who would do what? I think these sort of role-playing sort of, or scenario scheming type situations are helpful because certainly when the real thing happens, you know, it's helpful if you've got to be able to respond quickly because there's a lot that needs to be done, you know, in terms of tracking, patient notification, all these sorts of things. So, you know, I would suggest that your leadership team include, obviously, nursing leadership, physician leadership, even tech leadership, and issues with regards to who in infection control is going to be your contact. Certainly, I got to know our infection control people very well over the past few years, you know, through our work with regards to these issues. Well, thank you all. Thank you, Dr. Tonk, for a wonderful presentation, and Dr. Tonk and Muthulsami for joining the panel, and Jim for joining the panel. It is always a pleasure to hear from the three of you, and this paper is so important. We've come to the close of this presentation. As a reminder, a recording of this session will populate your GI LEAP account when it's available. This concludes the presentation on the ASG guidance paper, GI Endoscope Reprocessing, a Comparative Review of Organizational Guidelines, and a Guide for Endoscopy Units and Regulatory Agencies. We hope this information is useful to you and your practice. Thank you.

endoscope reprocessing

guidelines

Dr. Pushpak Tong

infection control

government regulations

communication

reprocessing steps

best practices