The Society of Gastroenterology Nurses and Associates (SGNA) is a 20-year-old organization of 7000 registered nurses and other health care providers. Much of our practice involves the use, maintenance, and reprocessing of endoscopic equipment.

The SGNA first published recommended guidelines for the care of endoscopic equipment in 1978. The most recent update was in 1990. In 1992, SGNA added an accountability statement to ensure strict adherence to cleaning and reprocessing procedures. Nowhere in Spach and colleagues' article [1] is there reference to SGNA's guidelines or to those of the American Society for Gastrointestinal Endoscopy.

Our Product Utilization Committee has reviewed the article and believes that the statistics in Tables 1, 2, and 3 are misleading because many of the reported infections were transmitted before the advent of submergible endoscopes in 1985. Most of the data after 1985 can be attributed to one flawed automatic washer design. Many examples in the article resulted from processing of the endoscopes using alternative methods. Cytology brushes were reused, and biopsy forceps were not processed according to recommended guidelines. In the period before 1985, the head of the endoscope and the umbilical cord with the light guide could not be submerged in any kind of fluid. If the endoscope was accidentally immersed, it sustained significant internal damage. Also, before 1985, all channels (specifically the umbilical cord) were not accessible to the passage of a brush. Brushing is imperative to loosen debris from the walls of the channels. The SGNA, in its 1990 monograph, recommends that all pre-1985 instruments be replaced with submergible endoscopes.

References from outside the United States (that is, from the World Congress of Gastroenterology Working Party) should not be used as standard practice in this country. The SGNA is collaborating with a consensus group of professionals who are writing American standards for the cleaning and disinfection of gastrointestinal endoscopes. Other participants in this group include physicians, microbiologists, government regulators, industry representatives, and other health care professionals.

Clearly, the complex and fragile structure of endoscopes presents problems in cleaning, disinfection, and sterilization. As the authors [1] note, "major reasons for transmission were improper cleaning and disinfection procedures; the contamination of endoscopes by automatic washers; and an inability to decontaminate endoscopes despite the use of standard disinfection techniques, because of their complex channel and valve systems". The SGNA recommends that the processing of contaminated equipment be done by specially trained personnel who strictly adhere to established protocol. Spach and colleagues quote Gorse and Messner [2], who cite the "problem of lack of administrative support, insufficient equipment and supplies, lack of involvement of infection control staff, pressure to shorten down time, and the complexity of equipment". The SGNA concurs that these problems must be addressed and remedied.