AORN’s New Evidence Based Guideline: Processing Flexible Endoscopes

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The Association of periOperative Registered Nurses (AORN) published “Guidelines for Processing Flexible Endoscopes” in February 2016. As part of the research, AORN completed an extensive search of over 3,000 published documents relating to endoscope reprocessing. They used the strongest evidence geared toward prevention of infection transmission for creating this comprehensive guideline. Each piece of evidence used as a reference was assigned an appraisal score (e.g., strong evidence, moderate evidence, or benefits balanced with harm) and that score is noted in brackets at the end of the recommendation.

The rationale behind this guideline is to provide guidance to perioperative, endoscopy, and sterile processing personnel for processing all types of reusable flexible endoscopes and their accessories. Below are some of the recommendations from this newly developed guideline.

  • Flexible endoscopes should be processed in an area designed and constructed to support processing activities. The endoscopy processing room can be a single or two separate processing rooms. There needs to be two appropriate decontam sinks and a hand wash sink. The processing rooms should include instrument air, eyewash stations and HVAC design parameters (air exchanges, airflow patterns, humidity limitations and temperature) are discussed. If endoscopy processing is a one-room design there should be a minimum of 3 ft. between the decontamination area and the clean work area, and a separating wall or a barrier that extends a minimum of 4 ft ) above the sink rim.
  • Endoscopes should be processed the same way in all processing locations within the organization. Clean surgical attire should be worn in both the procedure room and the processing room of the endoscopy suite. Proper PPE includes surgical masks in combination with eye protection devices, such as goggles, glasses with solid side shields, or chin-length face shield; fluid-resistant gowns; general purpose utility gloves with cuffs that extend beyond the cuff of the gown; and fluid-resistant shoe covers.
  • Flexible endoscopes and accessories should be precleaned at the point of use in accordance with the endoscope manufacturer's instructions for use (IFU). A fresh solution for each new cleaning process should be used.
  • Used endoscopes and accessories must be transported to the decontamination area in a closed, leak-proof, puncture-resistant container or cart large enough to hold all contents. The transport container must be labeled with a biohazard label. Since biofilm start to form within minutes a procedure for recording the times that the endoscope procedure is completed and cleaning begins should be implanted.
  • After leak testing and before high-level disinfection or sterilization, flexible endoscopes should be mechanically cleaned (if compatible). Mechanical cleaning is recommended because it improves cleaning effectiveness, increases efficiency, minimizes personnel exposure, can be monitored for quality consistency. Cleaning and rinsing should be performed with the type of water, cleaning solution and brushes recommended in the IFU.
  • Flexible endoscopes, accessories, and associated equipment should be visually inspected for cleanliness, integrity, and function before use, during the procedure, after the procedure, after cleaning, and before disinfection or sterilization. The inspection should include the use of lighted magnification. Internal channels may be inspected using a camera or borescope. Cleaning verification tests such as adenosine triphosphate (ATP) or chemical reagent tests should be routinely used (e.g. after each use or daily) and for any new or borrowed scopes.
  • Flexible endoscopes and accessories should be mechanically high-level disinfected (HLD) or sterilized. AORN does not recommend manual HLD such as soaking in a tub or container.
  • A multidisciplinary team should conduct risk assessments to determine whether items that secondarily enter sterile tissue or the vascular system (ie, via a mucous membrane) should be sterile and whether the lumens should be flushed with alcohol.
  • Flexible endoscopes and endoscope accessories should be stored in a manner that minimizes contamination and protects the device or item from damage. Cabinets should be in a clean and secure location, but not within the procedure room. Drying cabinet that circulates filtered air and forces the air through the channels should be used. If the facility does not have a drying cabinet the scopes should be stored in a closed cabinet with positive pressure that circulates filtered air around the scopes.
  • Clean gloves should be worn when handling processed scopes. A multidisciplinary team should establish a policy to determine how long the scopes can be stored without being reprocessed prior to use.

Following these evidence-based recommendations can help minimizes the risk of infection transmission to patients by maximizing the effectiveness of flexible endoscope processing. AORN also provides a policy and procedure template as well as a competency tool based on this guideline.


1. AORN Guidelines for Processing Flexible Endoscopes. In: Guidelines for the Perioperative Practice. Denver, CO: AORN, Inc; 2016

2. 6 New Evidence-Based Practices For Implementing More Effective Processing Of Flexible Endoscopes in; AORN Periop Insider, 1/13/2016.

3. Putnam. K. Guideline first look: Guideline for processing flexible endoscopes; in Periop Briefings, 1/13/2016

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