Decontamination audit system for Auditing Infection Prevention and Control Standards in Endoscopy Units

Medical Audits Provide Quality Assurance for Decontamination Processes

Decontamination of Endoscopes - Infection Risks related to Endoscopes

Risk of Spread of Infection via endoscopes

Flexible endoscopes have been associated with more hospital acquired infections than any other device (Spach et al, 1993) and require unique decontamination considerations due to their design. Their external surfaces and internal channels for air, water, aspiration and accessories are all potentially exposed to body fluids and other contaminants. They are also heat labile and so cannot be autoclaved.

Most flexible endoscopes are classed as “semi-critical devices” as they come into contact with mucous membranes during use and so they require “high level disinfection”.

The term “high level disinfection” refers to processes that eliminate or kill all vegetative bacteria, mycobacteria, fungi and viruses, except for small numbers of bacterial spores.

Some flexible endoscopes, because they enter normally sterile body cavities are regarded as “critical devices”. Example choledochoscopes and those used for NOTES (natural orifice transluminal endoscopic surgery). These must go through a process of sterilisation rather than high level disinfection.

Endoscope decontamination is a specialist process and needs to be carried out in a designated Endoscopy Unit. This audit is designed and developed to assist you in assuring you meet the relevant standards and guidelines and identify areas for intervention.

Guidelines for Decontamination of Endoscopes in NHS and HSE hospitals

Guidelines on the management of endoscopes have been updated on many occasions since they were first published in 1988.

This audit was designed with reference to the most up to date NHS guidelines and has been prepared with reference to:-

  • The Report of an Independent Review of Endoscope Decontamination in Northern Ireland. (Department of Health, Social Services and Public Safety, 2005)
  • Multi society guideline on reprocessing flexible gastrointestinal endoscopes, (American Society for Gastrointestinal Surgery, 2011)
  • BSG guidance on decontamination of equipment for gastrointestinal endoscopy : the report of a working party of the British Society of Gastroenterology Endoscopy Committee (British Society of Gastroenterology, 2014)
  • Guidelines for the Prevention and Control of Infection from Water Systems in Healthcare Facilities ( Health Protection Surveillance Centre, Ireland, 2015)
  • Standards of infection prevention in reprocessing flexible gastrointestinal endoscopes, (Society of Gastroenterology Nurses, 2016)
  • Joint Advisory Group on Gastrointestinal Endoscopy (JAG) accreditation standards for endoscopy services, 2015
  • Health Technical Memorandum 01-01: Management and decontamination of surgical instruments (medical devices) used in acute care (2016)
  • Health Technical Memorandum 01-06: Decontamination of flexible endoscopes (2016)

This Audit system has been developed for the regular audit and assessment of infection control standards and decontamination standards in Endoscopy Units

Using Medical Audits Decontamination Audit system you can audit practice against the most up to date NHS decontamination standards and HSE decontamination code of practice as well as best practice guidelines for Infection Prevention and control in endoscopy units.

The decontamination audit system has been designed to assist identification of risks and training requirements, assess practice in relation to safe management of reusable invasive medical devices and evidence your compliance with relevant endoscopy unit standards.

Specifically designed for auditing decontamination Standards in Endoscopy Units, this audit system includes:
✔ Standards for endoscopy unit layout
✔ Water quality in endoscopy units
✔ Cleaning of endoscopes
✔ Inspection of endoscopes
✔ Storage of endoscopes
✔ Auditing tracing processes
✔ Staff training and education
✔ Maintenance of washer /disinfectors and autoclaves
✔ Monitoring compliance in clinical and procedure rooms,

All our audit systems are based on best practice standards and guidelines. They are developed in consultation with Infection Prevention experts and reference the following standards and guidance:-

✔ High Impact Interventions (NHS Improvement & IPS, 2017).
✔ Health Information and Quality Authority (HIQA) National Standards for the prevention and control of healthcare-associated infections in acute healthcare services (2017).
✔ Guidance for Application of Standards and Recommended Practices in Primary Care Local Decontamination Units (HSE, Ireland 2016).
✔ Standard Infection Control Precautions (SIPCs) (Health Protection Scotland 2016).
✔ Code of Practice for Decontamination of Reusable Invasive Medical Devices (HSE,2012)
✔ EPIC 3 Guidelines on prevention of HCAI in England (2012).

Medical Audits Auditing and Quality Assurance Systems Provide the Technology Systems for Monitoring Infection Prevention Standards across all areas of healthcare

More About Medical Audits Decontamination Audit and QA Systems

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Medical Audits Systems Support
Safe Decontamination Practices


Health Service Executive Code Of Practice For Decontamination Of Reusable Invasive Medical Devices
Health Technical Memorandum 01-06: Decontamination Of Flexible Endoscopes
Health Technical Memorandum 01-01: Management And Decontamination Of Surgical Instruments (Medical Devices) Used In Acute Care