Health Technical Memorandum

01-06: Decontamination of
flexible endoscopes
Part E: Testing methods

March 2016
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods

Health Technical Memorandum

01-06: Decontamination of
flexible endoscopes
Part E: Testing methods

ii
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iii
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods
Preface
Introduction
This HTM supersedes the Choice Framework
for local Policy and Procedures (CFPP) series,
which was a pilot initiative by the Department of
Health.
The CFPP series of documents are reverting to
the Health Technical Memorandum title format.
This will realign them with HTM 00 – ‘Policies
and principles of healthcare engineering’ and
‘HTM 01-05: Decontamination in primary care
dental practices’ and the naming convention
used for other healthcare estates and facilities
related technical guidance documents within
England. It will also help to address the
recommendation to align decontamination
guidance across the four nations.
In 01-01 and 01-06 DH will be retaining the
Essential Quality Requirements and Best
Practice format, this maintains their alignment
with HTM 01-05 and the requirement of ‘The
Health and Social Care Act 2008: Code of
Practice on the prevention and control of
infections and related guidance’ which requires
that “decontamination policy should
demonstrate that it complies with guidance
establishing essential quality requirements and
a plan is in place for progression to best
practice”. We are aware that policy within the
devolved nations differs on this particular issue
but the aim is that the technical content should
be consistent and able to be adopted by the
devolved nations so that the requirements of
the ACDP-TSE Subgroup’s amended guidance
can be met.
iv
The purpose of HTM is to help health
organisations to develop policies regarding the
management, use and decontamination of
reusable medical devices at controlled costs
using risk control.
This HTM is designed to reflect the need to
continuously improve outcomes in terms of:
• patient safety;
• clinical effectiveness; and
• patient experience.
Essential Quality Requirements and
Best Practice
The Health Act Code of Practice recommends
that healthcare organisations comply with
guidance establishing Essential Quality
Requirements and demonstrate that a plan is in
place for progression to Best Practice.
Essential Quality Requirements (EQR), for the
purposes of this best practice guidance, is a
term that encompasses all existing statutory
and regulatory requirements. EQRs incorporate
requirements of the current Medical Devices
Directive and Approved Codes of Practice as
well as relevant applicable Standards. They will
help to demonstrate that an acute provider
operates safely with respect to its
decontamination services.
Local policy should define how a provider
achieves risk control and what plan is in place
to work towards Best Practice.
Best Practice is additional to EQR. Best
Practice as defined in this guidance covers
non-mandatory policies and procedures that
aim to further minimise risks to patients; deliver
better patient outcomes; promote and
encourage innovation and choice; and achieve
cost efficiencies.
Best Practice should be considered when
developing local policies and procedures based
on the risk of surgical procedures and available
evidence. Best Practice encompasses
guidance on the whole of the decontamination
cycle, including, for example, improved
instrument management, where there is
evidence that these procedures will contribute
to improved clinical outcomes.
The HTM 01 suite is listed below.
• HTM 01-01: Management and
decontamination of surgical instruments
(medical devices) used in acute care
• HTM 01-04: Decontamination of linen for
health and social care
• HTM 01-05: Decontamination in primary
care dental practices
• HTM 01-06: Decontamination of flexible
endoscopes.
Note
This guidance remains a work in progress
which will be updated as additional evidence
becomes available; each iteration of the
guidance is designed to help to
incrementally reduce the risk of cross-
infection.
v
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods

Abbreviations

ACDP: Advisory Committee on Dangerous EWD: endoscope washer-disinfector

Pathogens
HCAI: healthcare-associated infections
ACDP-TSE [Subgroup]: Advisory Committee
on Dangerous Pathogens – Transmissible HCAI Code of Practice: DH’s ‘Health and
Spongiform Encephalopathies [Subgroup] Social Care Act 2008: Code of Practice for the
NHS on the prevention and control of
AE(D): Authorising Engineer (Decontamination) healthcare associated infections and related
guidance’
BS: British Standard
ISO: International Standards Organisation
CJD: Creutzfeldt-Jakob disease
MHRA: Medicines and Healthcare products
CQC: Care Quality Commission Regulatory Agency
DH: Department of Health sCJD: sporadic Creutzfeldt-Jakob disease
DIPC: Director of Infection Prevention and TSEs: transmissible spongiform
Control encephalopathies
EN: European norm vCJD: variant Creutzfeldt-Jakob disease

vi
Executive summary
Health Technical Memorandum (HTM) 01-06
provides best practice guidance on the
management and decontamination of flexible
endoscopes (principally gastrointestinal scopes
and bronchoscopes). In addition, this guidance
also provides advice on the management and
handling of an endoscope following use on a
patient at increased risk of vCJD.
This document covers flexible endoscope
management and decontamination only.
Clinical issues relating to endoscopy or the
manufacture of EWDs are not discussed. In
addition this document does not cover the
processing of flexible endoscopes used to
examine sterile body tissues. These
endoscopes should be sterile, possibly using
low temperature gas sterilization (for compatible
processes, see HTM 01-01 Part E).
HTM 01-06 is divided into five parts:
• Part A ‘Policy and management’ sets the
Department of Health’s (DH) policy
context and discusses the Essential
Quality Requirements and Best Practice
recommendations for an endoscope
decontamination service. Transmissible
spongiform encephalopathy (TSE)
infectious agents are discussed and
guidance is given on the management
and handling of an endoscope after it has
been used on a patient at increased risk
of vCJD.
• Part B ‘Design and installation’ gives
guidance on the design and fitting of
endoscope reprocessing units.
• Part C ‘Operational management’ gives
guidance on operational responsibility
together with advice on the procurement
and operation of an endoscope washer-
disinfector (EWD).
• Part D ‘Validation and verification’
highlights the types of tests and
maintenance procedures that are needed
to ensure that decontamination has been
achieved.
• Part E ‘Testing methods’ discusses the
principles and methods that are used in
the tests described in this HTM and the
tests detailed in BS EN ISO 15883-4.
Why has the guidance been
updated?
HTM 01-06 has been updated to take account
of changes to the ACDP-TSE Subgroup’s
general principles of decontamination (Annex
C). In relation to the decontamination of flexible
endoscopes, paragraphs C5 and C20 from the
Annex state:
Paragraph C5:
For endoscopes, the bedside clean should take place
immediately after the procedure has been carried out, and
it is recommended that the endoscopes should be
manually cleaned according to the manufacturer’s
recommendations and passed through an Endoscope
Washer Disinfector as soon as possible after use.
Paragraph C20:
A routine test for washer disinfectors could be developed
to measure the cleaning efficacy at validation and routine
testing, such as daily or weekly tests. This method could
be based on a process challenge device system that will
monitor the optimised wash cycles; the results must be
quantifiable and objective.
vii
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods
Essentially, therefore, this update focuses on
improving the washing and cleaning process,
reducing the time from patient use to the
decontamination process, and monitoring the
cleaning efficacy of endoscope washer-
disinfectors.
It is also important to point out that the ACDP-
TSE Subgroup’s Annex C deprecates the use
of ninhydrin in the detection of protein levels
because of its insensitivity. Alternative available
technologies should be considered for the
detection of residual proteins on the internal
surfaces of flexible endoscopes following
reprocessing. Therefore reprocessing units
should:
a. consider the available technologies and
make a risk-based decision on the
methodology to be adopted (for
example BS EN ISO 14971);
b. use technologies with the best available
sensitivity, consistent measurement
standards and quantifiable results to
measure effective control of residual
protein levels;
c. use trend analysis as a tool for self-
improvement to demonstrate decreasing
protein levels over time both on the
outside of the endoscope and the
lumens using available testing
technologies.
viii
Note
This remains a work in progress which will
be updated as additional evidence becomes
available.
List of major changes to Part E
since the 2013 edition
• CFPP 01-06 has reverted to the Health
Technical Memorandum title format and
now becomes Health Technical
Memorandum 01-06.
• “Automatic control test” changed to daily
test from weekly test to make it
consistent with schedule in HTM 01-06
Part D. This was an error in the previous
edition.
• New process challenge device efficacy
test introduced.
• New advice on tests for residual protein
detection introduced.
• Previous tests for residual soil using
ninhydrin and alternative methods now
removed as they are no longer
applicable.
• New test given in Chapter 6 for detection
of Pseudomonas aeruginosa in final
rinse-water.
• All references updated.
Acknowledgements

Andrew Bent Medicines & Healthcare products Regulatory Agenc

Anita C. Jones University of Edinburgh
Bill Keevil University of Southampton
Brian Kirk IHEEM Decontamination Technology Platform
Clive Powell Association of British Healthcare Industries
David Perrett Queen Mary University of London
Geoff Sjogren Institute of Decontamination Sciences
Geoffrey L. Ridgway, OBE, MD Clinical Microbiologist
Gerry McDonnell Association of British Healthcare Industries
Graham Stanton NHS Wales Shared Services Partnership – Facilities Services
Helen Griffiths Joint Advisory Group on gastrointestinal endoscopy (JAG)
Jackie Duggan Public Health England
James Ironside University of Edinburgh
Jimmy Walker Public Health England
John Singh Health Estates, Northern Ireland
Karen Chell NHS Supply Chain
Katy Sinka Public Health England
Mike Painter Public Health Physician
Mike Simmons Public Health Wales
Miles Allison British Society of Gastroenterology
Peter Hoffman Public Health England
Robert Kingston IHEEM Decontamination Technology Platform
Rod Herve University of Southampton
Sulisti Holmes Health Protection Scotland
Tony Young Southend University Hospital NHS Foundation Trust
Tracy Coates Association for Perioperative Practice

ix
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods

Contents

Preface������������������������������������������������������������������������������������������������������������������������������������� iv
Abbreviations��������������������������������������������������������������������������������������������������������������������������� vi
Executive summary���������������������������������������������������������������������������������������������������������������� vii
Acknowledgements����������������������������������������������������������������������������������������������������������������� ix
1 Introduction��������������������������������������������������������������������������������������������������������������������������1
2 Terminology��������������������������������������������������������������������������������������������������������������������������2
3 Automatic control test����������������������������������������������������������������������������������������������������������3
4 Drainage��������������������������������������������������������������������������������������������������������������������������������4
5 Venting system���������������������������������������������������������������������������������������������������������������������7
6 Water system������������������������������������������������������������������������������������������������������������������������8
7 Doors and door interlocks�������������������������������������������������������������������������������������������������� 18
8 Chemical dosing�����������������������������������������������������������������������������������������������������������������20
9 Instrumentation fitted to an EWD�������������������������������������������������������������������������������������� 21
10 Load carriers��������������������������������������������������������������������������������������������������������������������� 22
11 Thermometric tests����������������������������������������������������������������������������������������������������������� 23
12 Load dryness�������������������������������������������������������������������������������������������������������������������� 27
13 Chemical additive residual levels�������������������������������������������������������������������������������������28
14 Air quality��������������������������������������������������������������������������������������������������������������������������29
15 Sound pressure test���������������������������������������������������������������������������������������������������������30
16 Cleaning efficacy tests����������������������������������������������������������������������������������������������������� 31
17 Leak and patency testing�������������������������������������������������������������������������������������������������35
18 EWD self-disinfection test������������������������������������������������������������������������������������������������39
19 Disinfectant concentration test���������������������������������������������������������������������������������������� 42
20 Microbiological and temperature tests of disinfection efficacy��������������������������������������43
References������������������������������������������������������������������������������������������������������������������������������45

x

1 Introduction
1.1 This volume discusses principles and
methods that are used in the tests described in
this HTM and those detailed in BS EN ISO
15883 Parts 1 and 4.
1.2 EWDs for flexible thermo-labile endoscopes
are machines of Type 1 or 2:
• Type 1 EWDs have a single door or lid
entry.
• Type 2 EWDs have two doors and a
pass-through facility.
1.3 (Rigid endoscopes able to tolerate terminal
steam sterilization are considered under WDs
for surgical instruments.)
1.4 EWDs are characterised by a chemical
disinfection stage because the endoscopes to
1 Introduction
be processed will not withstand the high
temperatures required for thermal disinfection. It
is necessary to ensure that the disinfectant is
removed from the endoscope before it is used
on a patient; this is achieved by a post-
disinfection rinsing stage. Some EWD process
cycles are available that add disinfectant to the
final rinse-water. The level of disinfectant at this
stage should be shown to be non¬toxic to
patients. The microbiological control of this
stage is of critical importance to the microbial
status of the reprocessed endoscope. A
number of additional tests are required to
ensure that this aspect of the process is
properly controlled.
1.5 Periodic storage cabinet tests for flexible
endoscopes are given in Chapter 6 of HTM 01-
06 Part D – ‘Validation and verification’.
1
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods
2 Terminology
Cycle variables
2.1 The cycle variables are the physical and
chemical properties such as time, temperature,
pressure, flow rate, concentration, chemical
composition that influence the efficacy of the
cleaning and disinfection processes. Many of the
tests described in this HTM require the values of
cycle variables to be determined experimentally
and then compared with specified or standard
values.
2.2 An indicated value is that shown by a
visual display fitted to the EWD.
2.3 A recorded value is that shown on the
output of a recording instrument fitted
permanently to the EWD.
2.4 A measured value is that shown on a test
instrument, for example, a temperature recorder
attached to the EWD for test purposes.
2.5 A noted value is that written down following
personal observation of an indicated, recorded
or measured value.
Disinfection conditions
2.6 The disinfection conditions are the
ranges of the cycle variables that may prevail
throughout the chamber and load during the
holding time.
2.7 Endoscope disinfection conditions are
specified by the disinfection temperature
band (if above ambient) and disinfectant
concentration range. The disinfection
temperature band may be ambient temperature
or elevated above the incoming water
temperature to a defined level. A minimum
acceptable temperature, known as the
2
disinfection temperature, and a maximum
allowable temperature define the disinfection
temperature band.
2.8 Flexible endoscopes can withstand
temperatures up to 60°C, above which damage
is likely to occur. EWDs that dilute disinfectant
with water directly from the supply will vary in
their operation owing to the variation in the
supply water temperature and chemistry,
particularly between seasons. The disinfectant
contact concentration is specified by the
minimum acceptable concentration in contact
with the load to be disinfected and the maximum
allowable concentration.
2.9 For those EWDs in which the chemical
disinfection stage, or the cleaning stage, is
thermostatically controlled at elevated
temperature, the duration of the exposure to the
chemical may be determined thermometrically.
In most cases, investigation of the performance
of chemical disinfection processes can only be
carried out successfully using microbiological
test methods in conjunction with physical
testing.
2.10 The disinfection temperature band (if above
ambient) may also be quoted for liquid chemical
disinfection/sterilization processes, but is not a
complete specification of the disinfection
conditions, since the efficacy of such processes
also depends on the concentration of the
chemical agent.
2.11 Some EWDs use elevated temperature for
the self-disinfection stage. Control of this stage is
critical and should be monitored
thermometrically to determine the correct
conditions have been met in all parts of the EWD
chamber.

3 Automatic control test
3.1 The automatic control test is designed to
show that the operating cycle functions
correctly as shown by the values of the cycle
variables indicated and recorded by the
instruments fitted to the EWD.
3.2 In the absence of an independent
monitoring system (IMS), this test is carried out
daily and is the main test for ensuring that the
EWD continues to function correctly within the
validated parameters. The IMS records should
be checked in conjunction with the test.
Test procedure
3.3 Place a test device or a routine endoscope
in the chamber. Select the routine operating
cycle and start the cycle.
3.4 Ensure that a traceability record is made of
the test. Note chamber temperatures (if
appropriate), leak test pressure and time at all
significant points of the operating cycle, for
example the beginning and ending of each
stage or sub-stage.
3 Automatic control test
3.5 The test should be considered satisfactory
if the following requirements are met:
a. A visual display indicating “cycle
complete” occurs.
b. During the whole of the operational
cycle, the values of the cycle variables
as indicated by the instruments on the
EWD or shown on the batch process
record are within the limits established
as giving satisfactory results either by
the manufacturer or during validation.
c. If elevated temperatures are used during
the routine cycle, the time for which the
temperature is maintained is not less
than that established during validation.
d. The door cannot be opened until the
cycle is complete.
e. The person conducting the test does
not observe any mechanical or other
anomaly.
3
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods
4 Drainage
4.1 It is important to vent the EWD externally to
prevent any hazardous fumes entering the
workspace. This applies both to the drains that
should be sealed within the EWD work area
and to the EWD cabinet. There is no test to
determine if any gas contents of the EWD
chamber or drain enter the workspace.
Therefore if a potentially hazardous chemical is
used as the disinfectant, such as peracetic
acid, gas measurements should be taken
around the EWD during operation to determine
whether there are any leaks in the system.
Blocked-drain protection
4.2 If the drain from the EWD chamber
becomes blocked, continued operation of the
EWD would allow water and suspended soil to
be discharged onto the floor either during the
operating cycle or, for cabinet-type EWDs with
sealed door(s), by sudden discharge when the
door is opened at the end of the cycle.
4.3 The purpose of blocked drain protection is
to prevent unacceptable spillage and minimise
the risk of cross-infection.
4.4 In the test, the drain is deliberately blocked,
and successive operating cycles are run until
the water level is above the level of the door
seal. The test is intended for use both as a type
test (and as such is a requirement of BS EN
ISO 15883-4) and as an operational or
installation test.
Equipment and materials
4.5 Either a solid metal sphere of diameter 10–
15% greater than the internal diameter of the
4
trap or a large ballvalve is used to obstruct the
discharge from the drain.
Method for EWDs with sealed doors
4.6 Introduce the metal sphere (or equivalent
device) to block the drain, or fit a large ballvalve
and close the valve.
4.7 Close the door and start the operating
cycle. On completion of the operating cycle,
attempt to open the EWD door using the
normal release procedure.
4.8 If the door opens and the water level is
below the door seal, close the door and start
another operating cycle.
4.9 Repeat the operating cycle as many times
as necessary for either the water level at the
end of the cycle to be above the level of the
door seal or a fault to be indicated.
Method for EWDs without sealed doors
4.10 Introduce the metal sphere (or equivalent
device) to block the drain or ballvalve adjusted
to the closed position.
4.11 Start the operating cycle. On completion of
the operating cycle, if no water has been spilled
from the EWD and no fault has been indicated,
start another operating cycle.
4.12 Repeat the operating cycle as many times
as necessary for either water to be spilled from
the EWD or a fault to be indicated.

Results for EWDs with sealed doors
4.13 A fault should be indicated when, or
before, the water level in the chamber reaches
the level of the door seal. The door should not
be capable of being opened by the normal
release procedure; a tool, key or code should
be required.
Results for EWDs without sealed doors
4.14 A fault should be indicated before water is
spilled from the EWD. The operating cycle
should be stopped preventing further inflow of
water. A tool, key or code should be required to
restart the EWD.
Note
This test might not be required if the design
of the EWD prevents the water level within
the chamber or bowl reaching the level of the
opening.
Free draining of tanks, chamber,
load carriers and pipework
4.15 Residual water that does not drain from
the internal pipework of the EWD may provide
an environment for microbial growth; these
microorganisms may recontaminate the
disinfected load.
4.16 The following checks should be carried
out during type-testing, works testing and
installation testing to verify that – as designed,
built and installed – the EWD will effectively
discharge all the water from the system:
a. free draining of chamber and load
carriers – test by visual observation at
end of the cycle;
b. free draining of tanks – test by visual
observation on draining the tanks;
c. pipework flow to discharge point – test
by visual observation including use,
when necessary, of a spirit level.
4 Drainage
Efficacy of discharge through the
trap
4.17 The test is intended to verify that the
operating cycle is effective in purging the trap of
all waste and soil.
Equipment and materials
4.18 The following equipment and materials are
necessary:
• test soil appropriate to the type of EWD
being tested (see guidance given in
‘Performance qualification tests’ in the
‘Validation and verification’ volume);
• sampling tube of sufficient length to
reach the water trap in the drain of the
EWD and a sampling pump (for example,
a pipette pump or syringe).
Method
4.19 The test may be carried out as part of the
cleaning efficacy test during operational testing.
4.20 On completion of an operating cycle to
test the cleaning efficacy by processing a full
load contaminated with an appropriate test soil,
place the sampling tube into the water trap and
remove a sample for examination.
4.21 Examine the water sample from the trap
for residual test soil using the detection method
appropriate to the test soil.
Results
4.22 The water in the trap should be free from
residual soil at the same level of detection as
that specified for the load items.
Residual soil in the trap may present an
infection or recontamination hazard.
Estimation of dead volume of
pipework
4.23 Residual water that does not drain from
the internal pipework of the EWD may provide
5
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods
an environment for microbial growth; these
microorganisms may then recontaminate the
disinfected load.
4.24 The test is intended primarily as a type
test but may also be of value, if possible, as an
operational test or when investigating microbial
contamination occurring in an EWD.
4.25 The test should only be carried out after
completion of the checks for free drainage (see
paragraph 4.15, ‘Free draining of tanks,
chamber, load carriers and pipework’) have
been satisfactorily completed.
Equipment
4.26 Volumetric measuring vessels of
appropriate size are necessary.
Method
4.27 The pipework of the EWD that is known to
be dry (either following disassembly and
6
reassembly or purging with dry compressed air
for not less than 30 minutes) is flushed with a
known volume of water (simulating the flow that
would occur in normal use).
4.28 The volume of water flushed through the
system should be twice that determined as the
volume used per operating cycle given in the
manufacturer’s data sheet. The volume of water
discharged is measured, and the dead volume
(estimated as the volume retained) is calculated
from the difference between the two values.
4.29 When the EWD has two or more pipework
systems that are entirely separate (for example,
for flushing water, wash-water, rinse-water, final
rinse-water), each system may be tested
separately.
Results
4.30 The volume of retained water should be
less than 1% of the volume of water used.

5 Venting system
Load contamination from ductwork
5.1 The evolution of water vapour from the
chamber during the washing stage, disinfection
stage and drying stage may result in
condensation occurring in the ductwork and in
the condenser (if fitted). The ducting is
commonly arranged to allow this condensate to
drain back into the chamber or drain. This
condensate is likely to become contaminated
and there is a risk that it could come in contact
with the load. The ductwork should be checked
at installation to confirm that any condensate
from the ductwork cannot drain into the EWD
chamber and onto the load.
Droplet emissions
5.2 Emissions of water droplets present a risk
of transmitting infection from contaminated load
items. The test is designed to be carried out as
an operational test.
Equipment and materials
5.3 The following equipment is necessary: cold
hand mirror.
Method
5.4 The EWD should be operated with the
chamber empty except for any chamber
furniture (for example, load carrier). Any
chemical additives used should be replaced
with water.
5.5 Close the door of the EWD. Initiate an
operating cycle. The cold mirror is moved
around the edge of the door or lid at a distance
of 50–100 mm from the door or lid.
5 Venting system
5.6 If the mirror shows any signs of misting or
the presence of droplets, its position should be
noted.
Result
5.7 There should be no misting of the mirror or
droplets present. Misting or droplets on the
mirror indicates the discharge from around the
door or lid.
Chemical vapour emission
5.8 EWDs use chemical additives for which
there may be specified exposure limits (usually
disinfectants) under the COSHH Regulations. It
must be ensured that emissions from the EWD
do not cause personal exposure to exceed the
legal limits.
Method
5.9 The method of sampling for airborne
emissions and the method of analysis or
detection will be specific to the chemical
additive(s) being used. Advice should be sought
from the EWD manufacturer, the supplier of the
chemical additive(s) and/or the Health & Safety
Executive (HSE) in order to determine an
appropriate test method.
Results
5.10 Emissions from the EWD during normal
operation and maintenance, including when
opening the EWD at the end of the cycle or
when changing or refilling chemical additive
reservoirs, should not expose personnel to
concentrations in excess of the legal maxima.
7
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods

6 Water system

6.1 A continuous supply of water of the Water samples

specified chemical and microbial quality is
essential to the correct functioning of all EWDs. 6.4 Water samples should be obtained from
Water that is too hard or has too high a either:
concentration of total organic carbon may • draw-off points installed at convenient
impair the activity of detergents (or require the locations within the system for testing the
use of increased quantities of chemical supply; or
additives) and cause deposits, scaling or
corrosion of the items being processed. • the EWD chamber or bowl for testing the
water rinsing the endoscope.
6.2 Water containing high numbers of
microorganisms may recontaminate disinfected 6.5 The sampling containers used should be
items. For all these tests, the water should be specific for the contaminants of interest. This
sampled from the water supply to each EWD or should include, as appropriate:
the EWD chamber/bowl. Additional samples
a. 250 mL sterile, chemically clean, single-
may need to be taken from any water treatment
use containers (for determination of TOC
plant when trying to identify the cause of
levels and/or total viable count);
non¬conformity.
b. containers supplied by the laboratory for
6.3 Periodic final rinse-water tests and measurement of chemical contents, for
satisfactory results are shown in Table 1. example:
Table 1 Periodic final rinse-water tests: satisfactory results
(i) 1 L acid-washed borosilicate bottles,
Water test Satisfactory Frequency (for determination of cations);
(click on link) results
(ii) 1 L polypropylene bottles (for
Total organic carbon Less than 1 mg/L Yearly
determination of anions and total
Appearance Clear, bright and Yearly
colourless
dissolved solids);
pH 5.5 to 8.0 Yearly (iii) 100 mL high-density polyethylene
Electrical conductivity Less than 40 µS/cm Weekly bottles (for determination of pH and
at 25ºC
conductivity).
Hardness Less than 50 mg/L Weekly (if
CaCO3 appropriate)
6.6 The first 100 mL of sample taken at each
Total viable count Less than Weekly sampling point should be run to waste.
(see also Table 3 in HTM 10 cfu/100 mL
01-06 Part B) acceptable
6.7 Samples for TVC should be chilled and
Environmental Non-detected in Quarterly
mycobacteria 100 mL samples tested within four hours of collection or stored
Pseudomonas aeruginosa Non-detected in Quarterly at 2–5°C and tested within 24 hours of
100 mL samples collection.

8

Water quality tests
6.8 The following sections describe analytical
methods that may be used to determine the
various biological, physical and chemical
properties of water samples.
6.9 The methods of analysis required to detect
chemical contaminants at low concentrations
with a high level of accuracy require the use of
a laboratory with appropriate expertise, facilities
and experience. Other tests can be carried out
on-site or with limited laboratory facilities; these
lack the precision and sensitivity of laboratory
tests, but are sufficient for most purposes.
6.10 This HTM contains detailed procedures for
tests that may be carried out on-site or with
very simple laboratory equipment at, or shortly
after, the time of sampling.
6.11 The precision, accuracy, sensitivity and
limits of detection of these methods are usually
inferior to those of laboratory methods. They
are useful, however, in that they provide
evidence of any gross failure, and the results
are available immediately, making them of
diagnostic value during a fault-finding exercise.
Choice of method
6.12 For any given determinant there will usually
be several methods that are suitable and cover
the range of concentrations of interest. The
methods given in this section are examples of
tests that may conveniently be carried out on
site.
6.13 A number of test systems are available
commercially. Before adopting one of these
methods, care should be taken to ensure that
the test(s) provides results of sufficient accuracy
and sensitivity. The User is responsible for
obtaining the test data and will require the
assistance of the AE(D) and AP(D) to decide
how the tests are carried out and who carries
them out.
6.14 It is not necessary to use experienced
chemical analysis staff to undertake these on-
site tests. It is, however, essential that personnel
6 Water system
receive appropriate training before attempting
to carry out this work. Recourse to more
precise analysis may be needed in the event of
a dispute between two parties.
Water supply temperature
6.15 The water supplied to the various stages
of the EWD operating cycle should be at an
appropriate temperature. If the temperature of
the water supplied to the flushing stage is too
high (>45°C), there is a risk of coagulating
proteinaceous soiling, which will inhibit the
cleaning process. If the temperature of water
supplied to the EWD is heated and its
temperature is too low, washing, rinsing and
disinfection stages may be greatly extended or
ineffective.
6.16 Water supplied to an EWD may be limited
to 30°C within the EWD; therefore, water supply
pipes running parallel to a hot water supply may
not be cool enough in warm weather to be
acceptable.
6.17 Storage of water between 10°C and 55°C
is liable to become contaminated unless good
water hygiene is practised (see Health Technical
Memorandum 04-01 for further guidance).
Equipment
6.18 An indicating or recording thermometer is
necessary.
Method
6.19 The temperature of the water supply
should be measured from a sampling point as
close to the EWD as possible. Place the
temperature sensor in the middle of the flowing
stream as close as practicable to the sampling
point. Allow the water to flow for at least a
minute before the temperature is read.
Alternative method (for periodic testing)
6.20 When it is not convenient, or practicable,
to run the water to waste from a sampling point
close to the EWD, the water temperature may
be estimated by measurement of the
9
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods

temperature of the outer surface of the supply Method

pipe. If this method is to be used, the
correlation between the temperature of the
water flowing out of the pipe and the surface
temperature of the pipe at a particular point
should be established during installation testing.
The surface temperature should be measured
using a sensor designed for the purpose, and
the manufacturer’s instructions for ensuring
good thermal contact with the surface should
be followed. The temperature should be noted
or recorded during a normal operating cycle not
less than 30 seconds after the start of water
flow through the pipe to the EWD.
Results
6.21 The noted value should be within the
temperature range specified for the installation.
Water supply pressure
6.22 If the pressure of the water supply to the
EWD is below the minimum pressure specified
by the manufacturer, the performance and
productivity of the EWD will be adversely
affected.
6.23 If the pressure of the water supply to the
EWD is above the maximum pressure specified
by the manufacturer, the capacity of overflow
devices may be inadequate, the designed
performance characteristics of valves etc may
be exceeded, and in extreme cases there may
be the risk of damage to components of the
EWD or to the products being processed. (For
example, many flexible endoscopes are likely to
be damaged if subjected to internal pressures
greater than 35 kPa.)
6.26 The pressure sensor should be connected
to each of the water supply pipes to the EWD,
as close to the EWD as may be practicable, on
the supply side of the EWD isolating valve for
that supply. The static pressure when the valve
is closed and the pressure indicated throughout
a normal operating cycle should be recorded or
observed and noted. When the water service
also supplies other equipment on the same
supply line, the test should be run both with the
other equipment operating throughout the test
(or their operation simulated by an appropriate
discharge to waste) and with no other
equipment operating.
Results
6.27 The water pressure should remain within
the supply pressure limits specified by the EWD
manufacturer. The test may be repeated if there
is more than one water supply (for example,
mains water and pure water).
Appearance
6.28 All the water supplied to the EWD should
be clean, colourless and free from visible
particulate matter. The appearance of the
sample is assessed visually.
Equipment
6.29 The following equipment is necessary:
• clean clear-glass bottle and stopper;
• filter paper (qualitative grade), filter funnel
and holder.

6.24 This test should be carried out as an Method

installation and/or operational test. It should be
6.30 A water sample should be transferred to a
repeated when any change is made to the
clear colourless glass bottle, which should then
water services supplying the EWD (including
be tightly stoppered. The sample should be
the connection or removal of additional
shaken well and examined visually against a
machines).
white background with a black line running
through the middle, preferably in a north light.
Equipment
6.25 A pressure indicator or recorder (0–10 bar) 6.31 If the sample is turbid, it should be filtered
is necessary. through a qualitative grade filter paper. The filter

10

paper should be examined and a description of
the retained material reported. The filtrate
should then be visually examined for deposits.
6.32 The appearance should be reported in
terms of both colour and the intensity of any
colour. If the sample is coloured, it should be
examined carefully to see whether evidence of
colloidal material is present.
6.33 To determine whether there is a problem
with water deposits, draw off approximately
300–500 mL of water into a clean glass beaker
or jar. Allow the water to settle and any air
bubbles to disperse. Then examine the sample
against a white sheet with a black line across
the centre under a good light. The water should
appear crystal clear with a distinct line between
the black and white areas. The presence of fine
deposits will be seen as slight opalescence and
a slightly indistinct edge to the black to white
areas.
Results
6.34 All the samples tested should be clear,
bright and colourless.
pH
6.35 Two suitable methods for on-site
measurement of pH are available; the colour
disc comparator and portable pH meter. If
colour comparators are used, the operator
should undertake a colour blindness test to
confirm they are able to read the results.
Equipment
6.36 The following equipment is necessary:
a. pH meter:
(i) There are several commercially
available small, portable pH meters.
A number of these include built-in
temperature compensation. Although
they provide suitable accuracy for
most general applications, they are
not well suited to measurement of
pH in solutions of low ionic strength.
Their use for the determination of pH
6 Water system
in water of high purity may give
unstable or unreliable readings.
(ii) Only those pH meters specifically
designed for the measurement of low
ionic strength solutions should be
used for determining the pH of
deionised or RO water.
b. Colour disc comparator:
(i) Colorimetric tests for pH are suitable
for high purity, low conductivity, and
water samples of the type to be
tested.
(ii) Since colorimetric methods are being
used for other field tests, this may be
the more appropriate method.
(iii) The accuracy is limited and
discrimination may not be better than
0.2 pH. This is, however, quite
suitable for field tests.
(iv) Colour, turbidity or strong oxidants in
the sample all interfere with the test.
(v) A narrow range indicator (or two for
use on successive samples) should
be chosen to cover the required pH
range from 4 to 8. Manufacturers of
colorimeters usually provide
indicators to cover a range from 2 or
3. Wide range indicators should not
be used because of their poor
discrimination.
Method
6.37 The test kit should be operated in
accordance with the manufacturer’s
instructions. Particular attention should be paid
to using accurate volumes of both sample and
reagent, and monitoring both temperature and
reaction time.
6.38 The colour of the reacted sample is
matched against the calibrated colour disc
viewed through a blank sample. The value in
pH units is read directly from the disc.
11
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods
6.39 The calibration should be verified using
standard buffer solutions made up in advance
and kept in capped bottles until required. The
buffer solutions should be chosen to have a pH
in the midpoint of the range of calibrated colour
discs to be used in the determination.
Results
6.40 The indicated value should be in the range
5.5 to 8.0.
Note
Photometric apparatus with somewhat better
discrimination is also commercially available.
Electrical conductivity
Equipment and materials
6.41 A meter suitable for measuring the final
rinse-water of a EWD should cover the following
range:
Range Resolution Accuracy
0–199 µS/cm 0.1 µS/cm ±1% full scale
6.42 It should be temperature-compensated
over the range 0–40ºC.
Method
6.43 The meter’s calibration should be verified
against commercial standards or 0.0005 molar
solutions of potassium chloride and pure water
can be used as working standards. These give
conductivities at 25ºC of 84 µS/cm and <0.06
µS/cm.
6.44 The potassium chloride solutions may be
prepared by dilution of a 0.1 molar solution.
6.45 The working standards are stable for up to
one week when stored in cool condition, in a
well-stoppered container.
6.46 A comprehensive range of standard
conductivity reference solutions, including pure
water standards (also known as absolute
water), are available commercially, standardised
12
at 25ºC and traceable to national standard
reference materials.
6.47 After calibration, the sample cup, or
immersion probe, should be thoroughly rinsed
with pure water.
6.48 The sample should be collected in a high-
density polyethylene bottle and tested as soon
as practicable.
6.49 An aliquot of the sample should be poured
into the sample cup of the conductivity meter
or, for meters with an immersion probe, into the
clean beaker. The meter manufacturer’s
instructions for making the measurement
should be followed; this will usually require a
short stabilisation period before noting the
reading.
Results
6.50 The conductivity at 25ºC should not
exceed 40 µS/cm for final rinse-water in contact
with the reprocessed endoscope, unless it
contains a biocide.
Hardness
6.51 Hardness of water is due to the presence
of dissolved salts of the alkaline earth metals
(calcium, magnesium and strontium). Their
presence causes limescale formation from
heated or evaporated water. This may inactivate
detergents and disinfectants and cause scaling
on load items.
Method a: ISE method
6.52 Ion-selective electrodes (ISE) can detect
calcium and divalent cations (total hardness).
ISEs are not specific for a particular ion but
have a relative selectivity for a particular ion or
group of ions. They provide a potentiometric
response to the activity of the ions in solution.
The activity is proportional to the concentration
for solutions of the same ionic strength.
6.53 Both analyte and calibration standard
solutions should be adjusted to the same ionic
strength. A high impedance millivoltmeter is

used to measure the potential between the ISE
and a suitable reference electrode. The
measured potential is proportional to the
logarithm of the concentration of the ion(s) in
solution.
6.54 The optimum working pH range is 4–9
and the ionic strength of the sample should be
adjusted for ionic strength. An adjustment
buffer consisting of 4 M potassium chloride
solution is often used. Phosphate buffers
should not be used, since the calcium activity
will be lowered by complexation or precipitation.
6.55 The electrodes are free from any major
interference except zinc ions. They are however
poisoned by a number of biological fluids.
6.56 The calcium electrode requires a single
junction reference electrode. Calibration is
made against two or more standard solutions.
These are commercially available.
Range
6.57 Calcium-selective electrodes should have
a Nernstian response for concentrations from 1
M down to about 5 x 10–6 M and a selectivity
ratio of better than 2000 against magnesium.
This range is suitable for analysis of softened
water and purified water (RO or deionised
water).
Method b: titrimetric method
6.58 Commercially available kits for the
titrimetric determination of both total hardness
and calcium hardness are available. They are
based on the same reaction in which divalent
cations are complexed with the disodium salt of
ethylenediaminetetraacetic acid (EDTA). When
the reaction is carried out, at pH 10–11, with
Eriochrome Black as the complexometric
indicator, all the calcium and magnesium ions
are chelated by the EDTA, and the absence of
free calcium and magnesium ions causes a
colour change in the indicator.
6.59 At pH values above 12, magnesium ions
are precipitated as the hydroxide and do not
react with the EDTA. Calcium hardness can be
6 Water system
determined using Patton and Reeder’s indicator
as a complexometric indicator.
6.60 The commercially available kits often use
novel titration methods instead of burettes. The
test reagents are specific to each kit. The
manufacturer’s instructions should be followed.
Range
6.61 Determinations within the range 5–400
mg/L can be made. The method is not
applicable to purified water or condensate from
clean or pure steam, which should have
calcium concentrations well below the range for
accurate determinations.
Results
6.62 The hardness expressed as mg/L CaCO3
should be within the following parameters:
• <50 mg/L for final rinse-water and water
used to dilute chemicals;
• 50–200 mg/L for water used in the
rinsing stages;
• >200 mg/L not suitable for use in an
EWD (if this is the only water grade
available, pre-softening is essential).
Total viable count
6.63 Endoscopes should be rinsed after the
disinfection stage to remove any residual
chemical toxicity. The rinse-water should be
free from extraneous material, both inorganic
and organic including microorganisms, which
could compromise the patient. Routine total
viable counts (TVCs) should be made on the
final rinse-water. If this water is collected from
the EWD bowl/chamber, it will have passed
through the water treatment system and internal
pipework of the machine. The TVC results will
give an indication of the water treatment system
performance and microbial colonisation of the
EWD pipework. If the TVC is high, additional
samples can be taken to determine the
problem source.
13
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods
6.64 The following test should be carried out as
an installation or operational test and as a
weekly periodic test for EWDs. It should be
carried out by a microbiologist or those trained
in aseptic techniques.
Equipment and materials
6.65 The following equipment and materials are
necessary:
a. sterile single-use containers with a
volume of at least 250 mL;
b. sterile filter membranes (47 mm
diameter, <0.45 µm pore size);
c. suction filtration apparatus;
d. incubator at 30±2ºC;
e. R2A agar (see BS EN ISO 15883-1,
Annex D) (alternatively yeast extract agar
(YEA) or tryptone soya agar (TSA) may
be used;
f. f70% alcohol and non-woven wipes.
Method: sample collection
6.66 Samples of final rinse-water should be
taken from the EWD using aseptic techniques
following the manufacturer’s instructions. If
these are not available, the advice of the AE(D)
should be sought. One of the following
methods may apply.
(1) From the EWD bowl – recommended
6.67 The following equipment will be required:
• A sampling tube made up of a length of
heat-resistant tube from the EWD bowl to
a sampling bottle held below the bowl
water level. The tube should be fitted with
a normally closed valve and a weight
attached to one end. The tube and
fittings should be sterilized before use.
• A water sampling container.
6.68 The EWD is run with an empty bowl using
a special cycle that allows the cycle to be
14
stopped during the final rinse with the bowl full
of water.
6.69 During the final-rinse stage of the EWD
cycle, stop the machine and the open the lid or
door. With gloved hand, remove the sterile
sampling tube from its wrap and place the
weighted end in the EWD bowl final rinse-water.
6.70 With the syringe pushed onto the open
end of the sampling tube, draw water down the
tube with the valve open. When the tube is full,
close the valve and remove the syringe.
6.71 Allow water to flow from the sampling tube
to waste, then open the sampling bottle and
direct the water sample into the bottle. When
the sample bottle is full, cap and label the
container with details of the sampling point and
the time and date the sample was collected.
(2) Using a sample bottle included in the EWD
load
6.72 This is an alternative method of sample
collection with two outlets fitted to the lid. One
connection is fitted to an EWD outlet via a
length of plastic tube. The other connection is
fitted with a short length of tube and left open.
6.73 During the EWD cycle, the bottle is
irrigated by the EWD process liquids, with the
last liquid being the final rinse-water. On
completion of the cycle, or if aborted at the end
of the final rinse stage, the bottle is removed
from the EWD and the connections removed
from the bottle and the openings sealed. The
full bottle of final rinse-water is labelled with
details of the sampling point and the time and
date the sample was collected and sent to the
microbiology laboratory.
6.74 The EWD manufacturer may describe
other methods of final rinse-water collection.
 6 Water system

will be required. One end of the tube is

Note
The final rinse-water may contain antibacterial
chemicals. If this is likely, a sterile neutralising
agent should be added to the container
before sterilization. This will prevent bacteria
from dying during transport to the laboratory.
As disinfectants used in EWDs contain a
mixture of antibacterial agents, advice from
the disinfectant manufacturer will be required
to select a suitable neutralising agent.
anchored in the bowl that is full of test water,
the other end attached to the syringe and a
siphon set up so that the bowl water sample
can be delivered into the test bottle without
contamination.
6.79 The sample should be chilled, transferred
to the laboratory and tested within four hours; if
this is not possible, the sample should be
stored at 2–5ºC for not more than 24 hours
before testing.

(3) From a collection tap

6.75 Wipe the discharge surfaces of the
sampling point thoroughly with 70% alcohol,
and allow to evaporate to dryness.
6.76 Run off not less than 500 mL through the
sampling point and discard.
6.77 Using aseptic handling techniques, collect
not less than 250 mL of sample in the sterile
container from running water and close the lid
securely. Label the container with details of the
sampling point and the time and date the
sample was collected.
6.78 If a sample is to be taken from an EWD
bowl, a length of sterile tube and sterile syringe
Method: testing
6.80 Filter a 100 mL aliquot of the sample
through a 0.45 µm filter. Aseptically transfer the
filter to the surface of a R2A, TSA or YEA plate
and incubate at 30±2ºC. Examine the plates
after 48 hours’ incubation and at five days. If an
urgent report is required, preliminary readings
could be made at 48 hours’ incubation and a
final report issued after five days’ incubation.
Carry out the test in duplicate.
6.81 Examine the filters and record the number
of colony forming units (cfu) that are visible.
Results
6.82 For EWD final rinse-water, see Table 2.

Table 2 Total viable count results guide

Aerobic colony count in 100 mL Interpretation/action Colour grade

Less than 1 Satisfactory
Green
1–9 on a regular basis Acceptable – indicates that bacterial numbers are under a reasonable level
of control Yellow

10–100 Risk assessment required to investigate potential problems and super-

chlorinate or repeat EWD self-disinfect Orange

Over 100 Risk assessment required to consider taking EWD out of service until
water quality improved Red

Notes:

Microbiological results from weekly tests should be plotted on a graph to give a trend. This will allow the “normal” and “unusual” results
to be distinguished for a particular situation. Investigation of unusual or unsatisfactory results can then be undertaken if results demand
(for example, if routine results are below 10 cfu/100 mL, occasionally some of the results may be above 10 cfu/100 mL).

If a bacterial count above 10 cfu/100 mL is obtained from test water, identification of the species is advised. If a significant proportion of
the microbes appear the same species from their colonial morphology, carry out an oxidase test to presumptively identify Pseudomonas
spp. Then if the test is positive, further investigations are required to determine whether Pseudomonas aeruginosa is present.

Adapted from: Willis, C. (2006). “Bacteria-free endoscopy rinse water – a realistic aim?” Epidemiology and Infection. Vol. 134 No. 2, pp.
279–284.

15
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods
6.83 The above levels are suggested values
(see the ‘Water quality and water treatment’
section in the ‘Design and installation’ volume);
if an endoscope requires a higher level of
decontamination, a risk assessment will be
needed.
Environmental mycobacteria
6.84 Environmental non-pathogenic
mycobacteria present a particular problem
when they occur in the final rinse-water of some
instruments used for diagnosis. Cells of the
environmental mycobacteria are easily
confused, on initial detection, with pathogenic
mycobacteria and may lead to misdiagnosis.
Other mycobacteria that occur in water, for
example Mycobacterium kansasii and M.
chelonae, are opportunistic pathogens. The
test is intended as a performance qualification
test and periodic test. It should be carried out
in a suitable microbiology laboratory.
Equipment and materials
6.85 The following equipment and materials are
necessary:
• 250 mL sterile single-use containers;
• sterile filter membranes (47 mm diameter;
≤0.45 µm pore size);
• suction filtration apparatus;
• incubator at 30±2ºC;
The sample should be taken downstream of
any filter or other device or equipment
intended to remove or control microbial
contamination in the water supply.
• Middlebrook 7H10 agar plates;
Viable counts of a test suspension on the
medium of choice should not be statistically
different from those obtained on a published
quality control medium (Middlebrook 7H10)
proven to be appropriate for environmental
mycobacteria. The use of alternative media
may allow for a shorter incubation time if
validation data is available.
16
• 70% alcohol and non-woven wipes.
Method: sample collection
6.86 The sample is best collected from the
EWD chamber or bowl.
Method: testing
6.87 Filter a 100 mL aliquot of the sample
through a 0.45 µm filter. Aseptically transfer the
filter to the surface of a Middlebrook 7H10 agar
plate (or alternative media) and incubate at 30°C
± 2°C for 28 days.
6.88 Examine the cultures weekly and record
the number of colony forming units that are
visible.
6.89 If growth is observed, the cultures should
be transferred to a laboratory with established
expertise in mycobacterial identification so the
strains isolated can be identified.
Results
6.90 For EWDs in which the product is rinsed
after the disinfection stage, there should be no
recovery of mycobacteria from 100 mL of final
rinse-water.
Pseudomonas aeruginosa
6.91 Pseudomonas aeruginosa is a bacterium
commonly found in water but has a greater
potential to cause infection, particularly in body
sites that are normally sterile, than most other
bacteria found in that environmental niche.
6.92 The procedure for enumeration of
P. aeruginosa from EWD rinse water is based
on that in the HTM 04-01 suite of documents.
6.93 A water sample should be taken and
processed as for environmental mycobacteria
but with the variations given in paragraphs
6.94–6.95.
Equipment and materials
6.94 The agar the filter should be transferred to
is CN agar containing cetyl trimethylammonium

bromide and nalidixic acid at concentrations
that will inhibit the growth of bacteria other than
P. aeruginosa (commercial, validated
supplements for this purpose are available).
Other selective and differential agars are
available and acceptable if validated.
Method
6.95 The agar should be incubated at 37°C
(+0/–2°C) for 2 days. Any colonies that show a
blue-green pigmentation can be reported as
P. aeruginosa. Should there be any doubt,
colonies can be subcultured from the
membrane onto milk cetrimide agar and
incubated at 37°C (+0/–2°C) for 1 day. Examine
the plates for growth, pigment, fluorescence
and casein hydrolysis (clearing medium’s
opacity around the colonies). If the pigment
production is poor, expose the milk cetrimide
agar to daylight at room temperature for 2–4
hours to enhance pigment production and re-
examine. Other validated confirmatory testing
for identification of P. aeruginosa can be used.
Results
6.96 There should be no P. aeruginosa in
100 mL of final rinse-water.
Volume of water used per stage
6.97 During type-testing, the manufacturer
should be required to determine the volume of
water used during each stage of the cycle.
These data are used in calculations of the
service requirement.
6.98 In addition, during installation or
operational testing, the volume of water used
for each stage should be verified. If the volume
of water used is insufficient, the efficacy of the
cleaning and disinfection process may be
adversely affected. If the volume is greater than
that specified, an unexpected heavy demand
might be placed upon the water supply.
6 Water system
Equipment and materials
6.99 A water flowmeter (or volumetric
measuring equipment) is necessary.
Method
6.100 Three methods are available for
determining the volume of water used. The
method chosen will depend on which is most
convenient for the particular installation.
6.101 A water flowmeter may be fitted in each
of the water supply pipes, consecutively or
concurrently, and the flow over each period of
delivery is used to calculate the total volume of
water consumed during each stage of the
process. The EWD should be operated with the
chamber empty apart from the chamber
furniture. The flowmeter manufacturer’s
instructions for installation should be followed.
Particular attention needs to be paid to the
length of uninterrupted straight pipe required on
either side of the meter.
6.102 When the EWD is supplied from a readily
accessible tanked supply, the make-up to the
tank may be interrupted and the water level
marked. The volume of water required to
restore the level after an operating cycle stage
may then be determined by the addition of a
measured volume of water.
6.103 For those EWDs that discharge all the
water from each stage at the end of each
stage, a suitable estimate of the volume used
may be obtained by volumetric measurement of
the discharge from the drain.
Results
6.104 The volume of water used for each stage
of the cycle should be within ±5% of the volume
specified by the manufacturer.
17
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods
7 Doors and door interlocks
Cycle start interlock
7.1 The interlock should prevent a cycle being
started with the door or lid open.
Method
7.2 Leave the doors open and unlocked.
Ensure that all services are connected. Make
an attempt to initiate an operating cycle.
7.3 Close and lock the doors and make a
further attempt to initiate an operating cycle.
Results
7.4 It should not be possible to initiate a cycle
with the door(s) left open. With the door(s)
closed it should be possible to initiate an
operating cycle.
In-cycle interlock
7.5 An interlock is required to ensure that the
door(s) cannot be deliberately or inadvertently
opened while the EWD is in operation.
Method
7.6 Close and lock the door(s) and start the
operating cycle. While the operating cycle is in
progress attempt to unlock each of the doors.
Where practicable, visually inspect the
interlocks to verify engagement before
attempting to open the door.
Results
7.7 In these circumstances it should not be
possible to unlock any of the doors.
18
Double-ended EWDs
Method
7.8 Both during and between cycles, attempts
should be made to open both the loading door
and unloading door of the double-ended EWD.
Results
7.9 It should not be possible to open the
unloading door after initiation of a cycle until a
cycle has been completed satisfactorily.
7.10 It should not be possible for both doors to
be opened at the same time.
7.11 It should not be possible to open the
loading door until a cycle has been satisfactorily
completed and the unloading door has been
opened and closed.
On sensor failure
Method
7.12 Each sensor should be disabled in turn
and an attempt made to open each of the
door(s). Disabling sensors may be achieved
either by disconnecting the transducer or by
switching software in “engineers’ mode” to
simulate a sensor fault.
Results
7.13 In each case it should not be possible to
open the door(s).

Door opening force
7.14 The mechanism for opening the EWD door
should not require the use of excessive force.
Equipment
7.15 The following equipment is necessary:
a. spring balance calibrated in kilograms
with a range including 0–100 kg and
with an accuracy of ±1 kg over the range
0–100 kg;
b. non-extensible means of attachment of
the spring balance to the door
mechanism.
Method
7.16 The force required to initiate and sustain
the movement of the door-opening mechanism
is measured by interposing a spring balance,
aligned coaxially with the direction of movement
of the door-opening mechanism, between the
operator and the mechanism.
7.17 Where practicable, the undertaking of
checks should be avoided during an operating
cycle.
7.18 Attach the spring balance to the door-
opening mechanism. Open the door, note the
force required to initiate the movement and to
sustain the movement.
Results
7.19 The indicated value required to initiate or
sustain the movement of the door-opening
mechanism should not exceed 25 kg.
Failed cycle interlock
7.20 The interlock should prevent an operator
from removing a load in the normal manner at
the end of a failed cycle.
7 Doors and door interlocks
Method
7.21 During an operating cycle, one or more of
the services to the EWD should be interrupted
sufficiently to cause a cycle failure.
Results
7.22 A fault should be indicated. For double-
ended EWDs it should not be possible to open
the unloading door or lid; it should only be
possible to open the loading door or lid by
means of a special key, code or tool. Single-
door or single-lid EWDs should remain locked
and require the use of a special key or code for
access to the chamber.
Fault indication on sensor failure
7.23 A failure of any sensor used as part of the
control system of the EWD should cause a fault
to be indicated by the automatic controller.
Method
7.24 Each automatic control sensor is disabled
in turn to establish that a fault is indicated.
7.25 An operating cycle should be started.
During or before the stage of the cycle at which
the sensor is intended to provide data used to
determine the control of the cycle, the sensor
should be disabled.
7.26 Each sensor should be tested in both
open-circuit and short-circuit failure modes.
Result
7.27 A fault should be indicated during or at the
end of the cycle. It should not be possible to
open the door on a single-ended EWD or the
unloading door of a double-ended EWD.
19
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods
8 Chemical dosing
Reproducibility of volume admitted
8.1 The test is intended to verify the setting for
the dispensed volume of chemical additive(s)
and to ensure that it is reproducible within
defined limits. The test should be carried out for
each chemical dosing system on the EWD.
Equipment
8.2 A measuring cylinder to BS EN ISO 4788 is
necessary when compatibility with the chemical
additive to be measured has been established.
The size of measuring cylinder should be
appropriate to the volume of chemical additive
to be dispensed.
8.3 Alternatively a flowmeter of appropriate
range may be used.
Method
a. Disconnect the supply line to the
chamber as close as possible to its
discharge point into the chamber or
water circulation system.
b. Actuate the dosing system and collect
the discharged volume of the chemical
solution in the measuring cylinder.
8.4 Repeat the test three more times. Record
the volume dispensed on each test.
8.5 Take care when carrying out this test
as concentrated chemical may leak. Wear
gloves, full face visor and apron.
Results
8.6 Ignore the result of the first test.
8.7 The mean collected volume from the final
three tests should be within ±5% of the nominal
dispensed volume.
20
Indication of insufficient chemical
additives
8.8 The use of the correct volume of chemical
additive(s) is necessary for the correct
functioning of the EWD. The EWD should be
equipped with means to ensure that a cycle is
not initiated when there is insufficient chemical
additive remaining in the reservoir to complete a
cycle.
8.9 The test should be carried out for each
chemical dosing system on the EWD.
Method
8.10 A low level of additives is placed in the
dispenser reservoir and repeated cycles are
run.
8.11 Care is required since many of the
concentrates used are irritant or corrosive.
Water may not be an acceptable substitute
because, for many dosing systems, differences
in viscosity can affect the dispensed volume.
8.12 Fill an otherwise empty container with
sufficient chemical for more than two, but fewer
than four, operational cycles. Run the EWD on
three consecutive cycles. Estimate the volume
remaining at the end of each cycle (pre-marked
container, dipstick, or weight).
Results
8.13 The EWD should indicate at the beginning
of the third or fourth cycle that there is
insufficient chemical remaining to complete a
cycle and should fail to initiate a new cycle until
sufficient chemical is available in the reservoir.

9 Instrumentation fitted to an EWD
Verification of calibration
9.1 The calibration of instrumentation, including
recording systems, fitted to the EWD should be
verified by comparison with calibrated test
instruments during steady-state conditions, for
9 Instrumentation fitted to an EWD
example the pump pressure during the wash
stage.
9.2 This may be carried out concurrently with
other testing, for example during the automatic
control test of the quarterly periodic test (see
Chapter 3, ‘Automatic control test’).
21
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods
10 Load carriers
10.1 Load carriers come in a variety of forms
including cages, carriages and baskets. Their
correct functioning is essential to the successful
outcome of an EWD operating cycle. It is
important that they cannot easily be misaligned,
that they function correctly and that, when
applicable, they make good connection with
service supply points in the chamber and with
load items (when necessary).
Method
10.2 The alignment of load carriers, their
connection to water, air or chemical additive
supply in the chamber (when applicable) and
22
their connection to endoscopes should be
verified by visual observation.
10.3 Load carriers with rotary spray arms
should be checked to ensure that the spray
arms are free to rotate, both when the load
carrier is empty and when fully loaded.
10.4 Load carriers that have lumen connections
as part of their structure require special
attention. The connection from the body of the
EWD to the load carrier needs to be good else
fluids and air may leak from the connections,
invalidating system checks within the EWD.

11 Thermometric tests
11.1 Thermometric tests are required for both
thermal disinfection processes and chemical
disinfection processes if elevated temperature
forms part of the process cycle. If during the
self-disinfect or routine cycles elevated
temperatures form no part in the process,
these tests do not apply.
11.2 For self-disinfection, the time/temperature
of an A0 of 600 (for example, 80°C for 10
minutes) or higher is suitable (see BS EN ISO
15883-1, Annex B, for details of the A0 concept
and time/temperature relationships). The
disinfection temperature is measured at the
coolest surface to be disinfected.
11.3 The reference test loads to be used for
thermometric tests are given in paragraph
16.19, ‘Test loads’.
Chamber wall temperature for the
self-disinfection cycle (if applicable)
Equipment and materials
11.4 A temperature recorder complying with the
requirements specified in BS EN ISO 15883-1,
clause 6.2.1, and having no fewer than 10
sensors is necessary.
Method
11.5 Thermocouples should be located one in
each corner of the chamber, one in the centre
of the two side walls, one in the centre of the
roof of the chamber and one adjacent to the
temperature sensor used as the reference
sensor for chamber temperature. In addition, a
probe should be positioned adjacent to the
11 Thermometric tests
EWD's process control sensor and a probe
positioned in the centre of the chamber free
space.
11.6 The temperature attained should be
measured throughout three self-disinfect
cycles; they should be at least 60 minutes since
the machine was last used (a “cold start”).
11.7 The EWD should be operated empty
except for chamber furniture (for example, load
carriers).
11.8 Multi-chamber EWDs may be tested with
each chamber tested consecutively or
concurrently. In the latter case eight sensors will
be required for each chamber.
Results
11.9 The results should be the following:
a. The temperatures recorded on the
surface of the chamber should be within
0–5°C of the cleaning/disinfection
temperature throughout the holding
period for the cleaning/disinfection
stage.
b. The temperatures recorded on the
surface of the chamber should be within
±5°C of the set temperature for the
relevant stage throughout the holding
period for each of the other stages.
c. The temperature indicated/recorded by
the EWD instruments should be within
±2°C of that recorded by the test
instrument from the sensor adjacent to
the reference sensor throughout the
holding period for the disinfection stage.
23
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods
d. The temperature profile obtained for the
operating cycle should be consistent
within ±2°C for three test cycles.
Load carrier temperature during
self-decontamination (if temperature
used)
Equipment and materials
11.10 A temperature recorder complying with
the requirements specified in BS EN ISO
15883-1, clause 6.2.1, and having no fewer than
four sensors is necessary.
Method
11.11 Temperature sensors should be located
at two diagonally opposite corners of the load
carrier, in the approximate geometric centre of
the load carrier and adjacent to the temperature
sensor used as the reference sensor for
chamber temperature.
11.12 The temperature attained should be
measured throughout three operating cycles,
which should be at least 60 minutes since the
machine was last used. The EWD should be
operated empty except for the endoscope
carrier.
11.13 The load carrier should be replaced
between cycles with a load carrier at ambient
temperature.
11.14 Multi-chamber EWDs may be tested with
each chamber tested consecutively using
independent data-loggers to record the
temperature of the load carrier. A temperature
recorder with fixed sensors may be used to
record the temperature adjacent to the
reference sensor.
11.15 This test may be run simultaneously with
the chamber wall temperature test.
Results
11.16 The results should be the following.
24
a. The temperatures recorded on the
surface of the load carrier should be
within the range 0–5°C of the
disinfection temperature throughout the
holding period for the disinfection stage.
b. The temperatures recorded on the
surface of the load carrier should be
within ±5°C of the set temperature for
the relevant stage throughout the
holding period for each of the other
stages.
c. The temperature indicated/recorded by
the EWD instruments should be within
±2°C of that recorded by the test
instrument from the sensor adjacent to
the reference sensor throughout the
holding period for the disinfection stage.
d. The temperature profile obtained for the
operating cycle should be consistent
within ±2°C of the reference temperature
on all test points for all three test cycles.
11.17 Three independent data-loggers and a
temperature recorder having at least one
sensor may be used as an alternative.
Over-temperature cut-out (when
temperature is used for self-
disinfection)
11.18 The EWD is fitted with an over-
temperature cut-out to ensure that, in the event
of the automatic control failing to control the
temperature in the EWD, the temperature will
not rise to a level that would damage the EWD.
11.19 This test can also be used if temperature
forms part of either the wash or disinfection
stage of an operating cycle. Over-temperature
during these stages is likely to damage
endoscopes being processed.
Equipment and materials
11.20 A temperature recorder complying with
the requirements specified in BS EN 15883-1,
clause 6.2.1, and having no fewer than four
sensors is necessary.

Method
11.21 Temperature sensors should be located
at two diagonally opposite corners of the load
carrier, in the approximate geometric centre of
the load carrier and adjacent to the temperature
sensor used as the reference sensor for
chamber temperature.
11.22 The EWD, empty except for the load
carrier, should be operated on a normal
operating cycle.
11.23 During the stage of the cycle when the
maximum temperature is attained, the
temperature control system should be disabled.
Results
11.24 The over-temperature cut-out should
operate at a temperature no more than 5ºC
higher than that provided by any temperature
control or temperature-limiting device.
Temperature during routine cycle
11.25 Thermometric tests are required if the
EWD cycle uses temperature as part of the
routine cycle, either during cleaning, rinsing or
disinfection. If the EWD is not fitted with a water
heater or warm water is not supplied from an
external source, these tests are not required.
Equipment
11.26 Temperature sensors should comply with
BS EN ISO 15883-1, clause 6.2.1. The diameter
of the probes should be suitable for the internal
diameter of the lumens to be tested and not
reduce flow to an extent that reduces the
operation of the EWD.
Method
11.27 Twelve temperature sensors are used
and placed in the following positions:
• At two diagonal positions in the
chamber.
• One in the geometric centre of the lid
or door.
11 Thermometric tests
• One adjacent to each temperature
control sensor.
• One adjacent to each temperature
process recorder sensor.
• One attached to the endoscope control
head in contact with the metal surface.
• At least one probe into a distal end
lumen of the endoscope to a depth of
not less than 100 mm.
• Remaining probes distributed on the
outer surface on the insertion tube and
umbilical cord spaced at interval of 750
mm, or less.
11.28 The probes should be positioned in good
contact with the surfaces being tested. In
addition probes should be positioned to
monitor the slowest part of the chamber or load
that has been found, by previous testing, to be
the slowest to warm up.
11.29 Run the cycle used for the routine
processing of flexible endoscopes. If more than
one cycle is used for this purpose, and they
both use elevated temperature during the
process, both cycles will need to be tested.
Results
11.30 Note the maximum and minimum
temperatures for each probe throughout the
cycle:
a. The temperatures recorded on the
surface of the chamber should be within
5°C of the cleaning/disinfection
temperature throughout the holding
period for the cleaning/disinfection
stage.
b. The temperatures recorded on the
surface of the chamber should be within
±5°C of the set temperature for the
relevant stage throughout the holding
period for each of the other stages.
c. The temperature indicated/recorded by
the EWD instruments should be within
±2°C of that recorded by the test
25
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods

instrument from the sensor adjacent to e. If temperature is combined with a

the reference sensor throughout the chemical for cleaning or disinfection, the
holding period for the disinfection stage. chemical manufacturer should define
the minimum temperature required.
d. The temperature profile obtained for the
operating cycle should be consistent
within ±2°C for three test cycles.

26

12 Load dryness
12.1 The presence of residual water on cleaned
and disinfected items may interfere with the
correct functioning of the item, promote
recontamination and microbial growth or
prevent satisfactory subsequent disinfection.
12.2 The ability of the EWD to externally dry an
endoscope may be evaluated visually, but the
internal lumens and valves are hidden from view
and require an additional test. If the EWD cycle
claims to include a drying stage, this test
should be use to determine if the EWD lumens
have been adequately blown.
Method
12.3 Process the test device through a routine
cycle. On completion remove the load and
12 Load dryness
connect to an air supply with a pressure of
105–120 kPa. Place the distal end of the lumen
50–100 mm above a sheet of coloured crepe
paper.
12.4 Pass air down the test lumen and examine
the paper for dampness denoted by dark spots
on the paper.
12.5 Tests on endoscopes should be made on
all lumens, with the the air supply connected
from the control valve and the umbilical end.
Results
12.6 Report any water droplets that are
discharged from the test device. There should
be no water droplets discharge.
27
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods

13 Chemical additive residual levels

13.1 See ‘Residual chemicals’ from the

‘Operational management’ volume.

Method
13.2 The efficacy of the rinse process should
be tested using the normal dose of the
chemical additive on a normal operating cycle
with a surrogate device to simulate an
endoscope (see the ‘Performance qualification
tests’ section in the ‘Validation and verification’
volume). Analysis, by the method
recommended by the manufacturer, should be
carried out on the final rinse-water and on the
surrogate device.

28
 14 Air quality

14 Air quality

14.1 Many EWDs are fitted with air filters to

remove particulate material from the air
supplied to the drying stage. These filters are
often HEPA filters (for example, EU 12/13) of the
type used to remove bacterial contamination
from the air supply. When they are used as
general particulate filters, performance tests will
not normally be required for the filter or the filter
housing. If a filter is fitted to provide air free
from bacterial contamination for flushing an
endoscope without further processing, a
certificate of conformity should be available.

14.2 Microbial sampling will not normally be

required for either system unless otherwise
specified.

29
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods

15 Sound pressure test

15.1 This test measures the total sound power Method

radiated from the machine and should be
performed in a specially designed and
equipped test room. It is neither necessary nor
practicable to repeat the test on an installed
machine.
15.2 The perceived level of noise in the
immediate vicinity of the equipment during
operation is, however, of concern. The
perceived noise level depends not only upon
the sound power level of the equipment but
also on the acoustic properties of the
environment and other sources of noise. It
should necessarily be determined with the
EWD installed and working normally.
15.3 A failure of the sound pressure test need
not be an indication that the machine is faulty.
The problem might lie in the acoustic properties
of the room in which the machine is installed.
15.4 The sound pressure test should be carried
out in accordance with BS EN ISO 3746 by
suitably trained and experienced personnel.
The guidelines given in the following two
paragraphs are intended only for additional
guidance and are not the complete test
method.
15.5 Use the procedure specified in BS EN ISO
3746 for both the loading and unloading area if
these are not common (and plantroom if
present), to determine the following:
a. the mean A-weighted surface sound
pressure level;
b. the peak A-weighted surface sound
pressure level.
Results
15.6 The test should be considered satisfactory
if the following recommendations are followed:
a. the mean A-weighted surface sound
pressure level does not exceed:
(i) 55 dBA for an EWD installed in an
operating suite, ward, treatment
room or other noise sensitive area;
(ii) 70 dBA for and EWD installed in an
endoscopy reprocessing unit;
b. in both the loading and unloading area
the peak A-weighted surface sound
pressure does not exceed the mean
A-weighted surface sound pressure level
by more than 15 dBA.

30

16 Cleaning efficacy tests
Test soils/process challenge
devices
16.1 These tests are used to demonstrate the
ability of the EWD to remove soil and
contamination from the chamber, carriage and
channels to ensure the EWD is working to a
defined level of cleaning efficacy. Test soils are
used to simulate naturally occurring
contamination since the latter shows
considerable variation and is therefore more
difficult to use for standardised testing.
16.2 Process challenge devices containing
cleaning efficacy indicators are used to verify
that cleaning has been achieved. There are
many devices available for use. It is important
that manufacturers’ instructions are followed
correctly to ensure the EWD is working to a
defined level of cleaning efficacy. They can also
be used as an independent audit tool to
compare performance of processes. See also
paragraphs 4.20–4.21 in HTM 01-06 Part D –
'Validation and verification'.
Note
Commercial process challenge devices are
being developed whose challenge simulates
the attachment of prion protein to
endoscopes and whose analysis is
quantitative. When these become available
and have been validated, reprocessing units
are advised to consider their use in addition
to process challenge devices based on soils
in BS EN ISO 15883-5 Annex R.
16 Cleaning efficacy tests
Type tests
Using the test soil given in paragraph 16.5,
this test can be used as an optional test to
determine the water distribution and
cleaning efficiency of the chamber and load
carriers to ensure a good water distribution.
16.3 Cleaning efficacy should be determined
using the relevant test soil listed in ISO/TS
15883-5. This soil is used to test instruments
after an EWD cycle.
16.4 The relevant test soil in ISO/TS 15883-5 or
validated equivalent is applied to a reference
load or surrogate device of demonstrated
relevance (see BS EN ISO 15883-4 Annex F or
as specified in the relevant part of BS EN ISO
15883-4).
16.5 The test soil can be made from:
• water, 50 mL;
• glycerol, 30 mL;
• horse serum, 30 mL;
• dehydrated hog mucin, 5 g;
• unbleached plain flour, 2 g;
• aqueous safranine solution, 2 % mass
fraction, 1 mL.
Preparation and storage
16.6 Mix all the constituents together and
agitate in a stomacher to give a liquid of uniform
consistency. Use immediately or store in an
airtight container at 2–5ºC for not more than
31
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods
one month or follow the manufacturer's
recommendations.
Application and use
16.7 If the soil has been stored, allow it to
equilibrate to room temperature before use.
16.8 The test should be carried out using water
of a quality suitable for the system requirements
using a detergent recommended by the EWD
manufacturer. The EWD manufacturer should
provide guidance on the minimum water quality
suitable for the detergent recommended. All
tests should be run in triplicate and for each
series of tests each of the three tests should
meet or exceed the minimum acceptance
criteria.
Method of application
16.9 Apply soil to the inner surface of the test
pieces by injecting the soil into the tubes of the
surrogate device (approximately 5 mL into the 1
mm inner-diameter tube and 20 mL into each of
the 2 mm inner-diameter tubes). Lay the tubes
on a horizontal surface and roll them to
distribute the soil over the inner surface.
16.10 Hold them vertically to allow excess soil
to drain away. Apply a small amount of air to
each soiled tube from a syringe full of air to
blow out any residual soil. Then apply an even
coat of soil to the outer surface using the
paintbrush. Allow excess soil to drain from the
items and allow them to dry at room
temperature (15–25°C) for not less than 30
minutes and not more than two hours. To dry
the inner surface of the tubes, connect each
tube to a small air pump and pass air down the
tubes for the drying time.
Method of use
16.11 Connect each surrogate tube to the EWD
outlets with suitable connectors: one of the 2
mm inner-diameter tubes connected to the
biopsy lumen; and one of the 1 mm inner-
diameter tubes connected to the bridge lumen,
if used. Run a routine EWD cycle. After
completion of the wash cycle, the cycle should
32
be aborted, if possible. The test load should be
removed and examined for the presence of
residual soil. This test should be run in
duplicate.
16.12 The manufacturer should establish worst-
case conditions of temperature, detergent
concentration, surrogate device configuration,
based on illustrations in BS EN ISO 15883-4
Annex F, and water pressure/flow rate for use
during testing.
16.13 By analysing the fraction of soil removed
during the cleaning process when operated for
various time periods shorter than those that will
normally be used, a quantitative comparison of
cleaning efficacy can be made.
16.14 The recommended minimum operating
conditions given by the manufacturer should be
based on these data, which should be made
available to the User as part of the type-test
data sheets.
Operational tests
16.15 During operational tests of cleaning
efficacy with test soils, the disinfection stage
and drying stage should be disabled, unless it
can be demonstrated that inclusion make little
difference to the results.
Test soils
16.16 The choice of test soil to be used should
be that specified in the type tests or that
described in paragraph 16.2, which represents
a more realistic tissue residue.
16.17 Drying the deposited test soil is
important, as it has an influence on the difficulty
of cleaning. At least two hours plus or minus 15
minutes’ drying time is required, including
lumens. The soil should be spread on such that
it appears dry within the specified drying time.
After soiling lumen may be dried, by passing
down low pressure dry air for the required time.
16.18 These performance criteria include the
following:

a. The test soil formulation should be
validated as being of equal or greater
difficulty to remove than the naturally
occurring soils, which it is intended to
simulate.
b. The method of application to give a level
of soiling which is reproducible within
specified limits should be validated and
documented.
c. The method of detection of residual soil
should be quantitative; visual
assessment alone should not be
regarded as satisfactory.
d. The limit of sensitivity of the detection
method employed should be 30 µg of
protein or below per test swab.
e. For tests on the chamber walls and load
carrier and lumen, the detection method
should include a validated method for
quantitative detection of the residual soil
in situ or a validated method of removal
for example, by swabbing, for
subsequent evaluation.
Test loads
16.19 The test load should consist of items of
similar size, mass and materials of construction
to the range of EWD it is intended to process.
16.20 A surrogate device for investigation of
cleaning and disinfection may be constructed
from two 1.5 m lengths of polytetrafluorethylene
(PTFE) tube (2 mm inner diameter) and one 1.5
m length of PTFE tube (1 mm inner diameter).
These should be bound together at intervals of
approximately 15 cm. For EWDs with more than
three lumens, two sets of three surrogate
devices may be required so that each of the
machine’s lumens can be tested. Advice from
the EWD manufacture may be required to
select suitable test tube diameters.
16.21 As flexible endoscopes with irrigation
lumens include valve systems to control air and
fluids, these need to be simulated in a test
device. Examples of such devices are illustrated
in BS EN ISO 15883-4 Annex F. At present
17 Leak and patency testing
there are no standard designs for these test
pieces, but a design that simulates the internal
structure of a flexible endoscope would be
acceptable.
Procedure for chamber walls and load carriers
16.22 The chamber walls and load carrier
should be contaminated with the test soil in
accordance with the instructions for the test
soil.
16.23 The load surfaces are dried in air for 30–
120 minutes, including lumens.
16.24 A normal operating cycle should be run.
16.25 After completion of the wash cycle and
before the disinfection stage, the cycle should
be aborted. The chamber walls and load carrier
should be examined for the presence of
residual soil by the method prescribed for the
particular test soil.
16.26 It is important that the specified
quantities are used.
16.27 The test should be carried out in
duplicate for each type of operating cycle
available on the EWD.
Procedure for reference loads
16.28 This test should be run only after
satisfactory completion of the test for the
efficacy of soil removal from chamber walls and
load carriers. The test load should be
contaminated with the test soil in accordance
with the instructions for the test soil.
16.29 A normal operating cycle for the load
type under test should be run.
16.30 After completion of the wash cycle and
before the disinfection stage, the cycle should
be aborted. The test load, lumen, chamber
walls and load carrier should be examined for
the presence of residual soil.
33
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods
Results
16.31 The chamber walls and load carrier
should be free from the test soil to the extent
specified for the test soil employed.
16.32 The test load should be free from the test
soil and none should have been transferred to
the chamber walls or load carrier.
Periodic tests: residual protein
detection
16.33 These tests should be carried out
quarterly per EWD.
16.34 Test methods previously recommended
for detection of residual proteins have limited
ability to remove protein from surfaces, and
assays have been shown to be insensitive.
Alternative available technologies should be
considered for the detection of residual proteins
on the internal surfaces of flexible endoscopes
following reprocessing. Therefore reprocessing
units should:
34
a. consider the available technologies and
make a risk-based decision on the
methodology to be adopted (for
example BS EN ISO 14971);
b. use technologies with the best available
sensitivity, consistent measurement
standards and quantifiable results to
measure effective control of residual
protein levels;
c. use trend analysis as a tool for self-
improvement to demonstrate decreasing
protein levels over time both on the
outside of the endoscope and the
lumens using available testing
technologies.
Note
This remains a work in progress which will
be updated as additional evidence becomes
available.
 17 Leak and patency testing

17 Leak and patency testing

Leak test Equipment

17.1 The leak test is carried out to determine if
liquid can gain access to the inner cavity of an
endoscope, thereby causing extensive damage.
The leak test is carried out manually before the
endoscope is cleaned and again by the EWD,
either at the start of the process cycle or
throughout the cycle. It is important that the air
used to pressurise an endoscope does not
exceed the limit set by the endoscope
manufacturer, normally about 250 mbar.
17.2 The test described is based on the use of
a test device. This device needs to represent
the inner volume of the largest endoscopes in
use.
17.3 This consists of:
• Length of flexible tube approximately 1m
terminated at one end to fit onto the EWD
leak test connection and at the other end
terminated with a flow valve.
• To construct a test device, the internal
volume of the largest endoscope in use is
needed; this may be obtained from the
manufacturer. The internal volume of the
tube is calculated and additional volume,
to make up the volume equal to that of an
endoscope, can be supplied by an
additional pressure tight container as
illustrated in Figure 1.
• A convenient way of adding additional
volume to a tube is to cut the tube in half
and fit a suitable T-piece. To the T-piece
side arm connect a plastic bottle that is

Figure 1 Leak test surrogate device

Flow control

Connector to EWD
Endoscope internal
leak test port
volume – TV
CV
Container and tube
internal volume –
CV
Pressure transducer

Volume of container plus tube –CV = internal volume of endoscope –TV

35
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods
approximately the correct internal volume
required. A bottle of internal volume 100–
200 mL may be suitable.
• Pressure transducer able to read ±1 mbar
(±0.1 kPa) over the range of the EWD
operating pressure.
Procedure
17.4 Verify the calibration of the pressure
sensor.
17.5 Connect the test piece (see Figure 1) to the
EWD leak outlet port with the flow control valve
fully closed. Disable the pressure regulation
system on the EWD. Start a leak test. Record
the pressure at which the pressure relief system
operates Pmax. Continue the cycle to obtain a
steady reading on the transducer Pb. Check
that the readings of Pmax and Pb do not exceed
the manufacturer’s recommendations.
17.6 Fault condition – connect the test device
to the EWD and run a leak test. Adjust the flow
control valve to give a pressure greater than
that specified by the manufacturer (P1). The
flow valve is opened slowly and the pressure
transducer reading observed. The aim is to
increase the leak so the pressure within the test
device falls below P3 before time T3 is reached,
i.e. a leak is present. Confirm from the readings
Figure 2 Pressure/time graph for leak test
Pressure
Pmax
P1
P2
P3
Atmospheric
pressure
T0 T1
36
that an EWD fail condition has occurred and a
fault has been indicated.
17.7 Pass condition – adjust the flow control
valve to give a leak rate 80% less than the fail
value given by the manufacturer. Connect the
test device to the EWD and run a leak test. The
time for the test device pressure to fall to value
P3 should be greater than time T3, that is, low
or no leak. From the readings confirm that a
pass condition has occurred on the EWD and
no fault has been indicated.
17.8 The leak test characteristics are illustrated
by Figure 2, where:
• Pmax the pressure relief system should
operate below this pressure;
• P1 the leak test pressure;
• T1 the start of the leak test equilibrium
period;
• P2 pressure after initial equilibrium time;
• P3 pressure determined by EWD
manufacturer; the level of maximum
allowable leak within the leak monitoring
time;
• T2 start of leak test monitoring time;
• T3 end of leak test monitoring time; ∆
Time
T2 T3

• ∆P/T maximum leakage rate permitted
for the process to continue, i.e. just a
pass.
(P2 – P3 )
P/T
(T3 – T2 )
or
(P1 – P3 )
P/T
(T3 – T1 )
Note
At the start of the test the pressure should be
approximately 200 mbar (120 kPa) above
atmospheric pressure, unless otherwise
stated by the manufacturer. The leak test
monitoring period should not be less than 1
minute. The maximum leak rate should be no
greater than 2.5 mbar/min (0.25 kPa/min).
Lumen patency detection test
17.9 EWDs for endoscopes should be fitted
with means to ensure that each of the lumens
is patent so that disinfectant and rinse solutions
will flow through each lumen, even those that
have a control wire. In addition a test is required
to demonstrate if an endoscope lumen
becomes disconnected it will be detected.
Equipment
17.10 A surrogate device should be used to
demonstrate that the system for determining
the patency of each lumen is function correctly.
The surrogate device may be constructed by
Figure 3 Test piece for the partial blockage test
Sheath with end cut off glued to needle
17 Leak and patency testing
using a 1.5 m length of PTFE tubing (1 mm
inner diameter).
Method
17.11 For each lumen (air/water, biopsy, elevator
as relevant), connect a 1.5 m length of tubing of
the appropriate diameter and run an operating
cycle. On completion of the cycle replace one
of the tubes with a similar tube that has a Luer-
lock male connection. A hypodermic needle of
the appropriate size, with sheath attached and
the end cut off for safety reasons, is attached
to the 1 mm inner-diameter tube. Other small
lumen test pieces may be used, attached to the
1.5 m tube, as long as they present a partial
blockage to fluid flow. Another operating cycle
should then be run. Repeat the test, changing
the position of the partially obstructed tube on
each test.
Note
Each make of EWD and each lumen may
require a different size needle to obtain a
partial obstruction indication. Some EWDs
may have a very sensitive lumen blocking
system. In addition the pressure of fluid down
each lumen may be different; this will affect
the partial blockage detection system. Some
EWDs use air to detect blockage with
different sizes of needles from those that use
fluid flow for operation.
17.12 Needles from size 21 to 32 will be
required to determine at commissioning which
size is suitable for each lumen to give an
indication of partial blockage. Figure 3 gives an
illustration of a suitable test piece.
1 mm interior
diameter tube
needle
37
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods
Results
17.13 The EWD should indicate a fault for any
lumen to which the appropriate partially
obstructed surrogate device is fitted.
Lumen disconnection detection test
17.14 To demonstrate if an EWD can detect
disconnected lumens, fit a surrogate device to
each lumen of the EWD and confirm that the
EWD can run a routine cycle.
38
Method
17.15 Disconnect each lumen in turn and run a
process cycle. If the EWD can detect several
lumen disconnections in one cycle and record
the event, more than one lumen disconnection
can be tested for each process cycle.
Results
17.16 A satisfactory result is when the EWD fails
due to lumen disconnections and can indicate
which lumens are affected.

18 EWD self-disinfection test
18.1 This test is a type test to verify that the
EWD’s “machine disinfection” mode will
disinfect those parts of the EWD that come into
contact with fluids that are intended to, or may,
contact the load. The type test will be carried
out by the manufacturer on the chemicals
selected as suitable for the EWD cycle. If a
chemical is chosen that is not listed on the
type-test list, the following test scheme will be
required. It is not recommended that live
organisms are used as test material on EWDs,
as there is a risk to patient safety.
18.2 The process is intended to deal with the
situation where an EWD has become
contaminated and is routinely carried out at the
start of each working day. The piping used to
convey rinse-water to the endoscope, if
contaminated, may easily develop a layer of
biofilm containing many microorganisms in a
state, which is highly resistant to chemical
disinfection. This tubing should normally be
replaced at the interval specified by the
manufacturer.
18.3 Biofilm may also develop in EWD tubes
during storage after production and testing
before the machine is installed. The change of
pipework before commissioning may well save
time trying to clean existing tubes.
Thermal disinfection
18.4 Thermal disinfection systems should be
evaluated by thermometric monitoring of the
system with sensors placed at the parts of the
system most remote from the heat source. The
entire system should attain the required
disinfection time/temperature of values that
18 EWD self-disinfection test
have been validated against a test biofilm in a
similar manner to chemical disinfection (see
below).
Chemical disinfection
18.5 For chemical disinfection systems a
microbiological test will be required. The test is
designed to ensure that the self-disinfection
cycle will disinfect contaminated tubing by
evaluating the effect of the cycle against a
biofilm containing Pseudomonas aeruginosa.
Production of biofilm test pieces
Equipment and materials
18.6 The following equipment and materials are
necessary:
a. peristaltic pump;
b. The EWD may be equipped with auto-
or manually-selected self-disinfect
mode. The method may be thermal or
chemical and in the latter case may be
the same or a different germicide from
that used for chemical disinfection of the
load. The preferred method is thermal
disinfection or, if this is not possible, the
use of a different germicide. The use of
the same germicide carries the risk of
allowing organisms resistant to that
particular germicide to proliferate.
c. incubator at 30ºC ± 2ºC;
d. 1 L sterile conical flask fitted with rubber
bung, air vent and two sterile glass
tubes;
39
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods
e. sterile connecting tubing;
f. 1.5 m length of sterile 6 mm inner-
diameter PTFE tubing;
g. nutrient agar supplemented with 1 g/L
sodium desoxycholate;
h. 0.025 g/L of 2.4.4’-trichloro-2’-
hydroxydiphenylether;
i. Pseudomonas aeruginosa (ATCC
number 15442);
j. liquid growth medium: phosphate buffer
(containing 1.2 g/L sodium phosphate,
dibasic; and 0.5 g/L potassium
phosphate, monobasic);
k. containing 0.25 g/L sodium glutamate
and 0.1 g/L citric acid.
Method
18.7 A petri dish containing supplemented
nutrient agar should be inoculated with
Pseudomonas aeruginosa(ATCC number
15442) and incubated at 30ºC ± 2ºC for 36–48
hours.
18.8 A 1 L conical flask containing 500 mL of
the sterile liquid growth medium is inoculated
with mucoid colonies of Pseudomonas
aeruginosafrom the agar plate and incubated at
30ºC ± 2ºC for 18–24 hours. The flask is then
fitted with a bung through which passes an air
vent, filtered to 0.22 m, and two glass tubes,
one of which reaches to the bottom of the flask
and the other terminating above the level of
liquid in the flask.
18.9 The sterile glass tubes are connected, via
a peristaltic pump and short lengths of sterile
flexible tubing, to 1.5–2.0 m sterile PTFE tubing
(6 mm inner diameter). The culture is pumped
round the tubing system at 50–75 mL/min
throughout the incubation period. The system is
maintained in an incubator at 30ºC ± 2ºC for
72– 96 hours.
40
Evaluation of the self-disinfection
cycle
18.10 This test forms part of the type-test
scheme. The disinfectants tested by this
method will be detailed in the EWD
manufacturer’s data. Therefore select a
chemical from the manufacturer’s list;
otherwise, the following test will need to be
carried out.
18.11 A 30 cm section of the tubing, suitably
identified (for example, T1), prepared with
biofilm is subjected to the test procedure
described below:
a. A section of the piping in the endoscope
lumen irrigation system of the EWD is
removed and replaced with the test
system. The test system consists of two
30 cm lengths of the biofilm test piece
tubing connected via isolating valves
and Y-piece connectors in place of the
removed section of pipework.
b. It may be more convenient to connect
the test tubes, with isolating valves to
the biopsy lumen irrigation outlet on the
EWD. It should be confirmed that
disinfectant flows down this lumen
during self-decontamination.
c. With the valves open, the EWD is set to
operate a self-disinfect cycle. During the
test the EWD door or lid should be
open; this may require the EWD to
operate in “engineers’ mode” and
require the assistance of the
manufacturer.
d. At the end of any wash stage, and
immediately before the start of the
chemical disinfection stage, close the
valves isolating one of the test pieces
(T2). On completion of the disinfection
stage and any subsequent rinse stage,
remove both test pieces (T2 and T3) and
carry out the recovery procedure
described below.
e. Replace the test pieces with two more
sections of the tubing with biofilm and
 18 EWD self-disinfection test

carry out a further self-disinfect cycle. experimental error; the difference

Isolate one of the test pieces (T4) at the between them is a measure of the
end of the disinfection stage and before reproducibility of the system;
any rinsing process. On completion of
the cycle, remove both test pieces (T4 • T1 – T2 is the loss during the washing
and T5) and carry out the recovery stage;
procedure described below. • T3 – T4 and T5 – T4 are the losses during
the post-disinfection rinse;
Recovery procedure
• T2 – T4 is the loss due to the disinfection
18.12 The 30 cm length of tube should be cut process.
into six portions, each approximately 5 cm in
length. Three of these should be transferred 18.16 On testing the full self-disinfect cycle,
into individual universal containers containing there should be no recovery of organisms from
nutrient broth and incubated at 30ºC ± 2ºC. T3, T4 and T5. When this is the case, the test
should be repeated with the exposure time
18.13 The remaining three sections should be reduced to half the normal disinfection time.
cut in half longitudinally, and each pair This will require the manufacturer’s assistance,
transferred to 10 mL of quarter-strength and the EWD will need to be operated in
Ringer’s solution containing 0.05% polysorbate “engineers’ mode”. The reduced exposure time
80 in a thin-walled universal container. should give a reduction of at least 103 in the
number of recoverable microorganisms (T2 – T4
18.14 The container should be ultrasonicated ≥ 103).
for 10 minutes at between 30 and 50 kHz.
Tenfold serial dilutions should be prepared of 18.17 An alternative method is described in BS
the eluate obtained, and these should be used EN ISO 15883-4, clause 6.12.3.1.
for enumeration of the surviving organisms by
the spread plate technique or other appropriate 18.18 For the purposes of periodic testing, a
viable counting method. All determinations water sample taken from the bowl/chamber
should be carried out in duplicate. after self-decontamination examined for the
presence of bacteria should be sufficient to
Results determine whether the process has killed or
removed organisms from the pipe circuit.
18.15 The data obtained give the following
information:
• T1 – recoverable population on the
original test piece;
• T2 – recoverable population after the
washing stage;
• T3 – recoverable population after wash,
disinfect and rinse stages;
• T4 – recoverable population after wash
and disinfect stages;
• T5 – recoverable population after wash,
disinfect and rinse stages;
• T3 and T5 should have the same
population within the limits of

41
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods
19 Disinfectant concentration test
19.1 EWDs employing a chemical disinfection
stage may reuse the chemical disinfectant a
number of times (multi-use). Guidance on the
number of cycles for which a particular
disinfectant can be used is provided by the
chemical manufacturer. Owing to the variable
nature of the load, it is difficult to determine
exactly how many cycles the disinfectant will
remain active for. If a cycle counter is used to
indicate the exhaustion of the disinfectant, the
number of cycles should be set at a lower
number than recommended to allow for
endoscope variation and dilution of the
chemical by residual water.
19.2 When the disinfectant is used only once
and discarded, a disinfectant concentration test
is not required.
19.3 When such a system is employed, the
EWD should be equipped with means to
establish that the concentration of the active
ingredient(s) in the disinfectant is above the
concentration specified as the minimum
acceptable. (This may be in the form of a test
kit.)
19.4 The disinfectant concentration test is
carried out to establish that the means provided
is effective.
19.5 The full strength solution, unused (and if
necessary freshly prepared or activated), should
be prepared according to the manufacturer’s
42
instructions. When this requires the addition of
water, only distilled or purified water should be
used.
19.6 A dilution series should be prepared using
distilled or purified water.
19.7 If the concentration of fresh disinfectant is
C1 and the minimum concentration of usable
disinfectant is C2,the following dilutions should
be prepared:
a. C2 + [(C1 – C2)/10]
b. C2
c. C2 – [(C1 – C2)/10]
19.8 For EWDs with an automated disinfectant
detection system, the test is carried out by
transferring dilute disinfectant to the disinfectant
reservoir and attempting to start an operating
cycle. The EWD should indicate when the
concentration is insufficient.
19.9 For EWDs where there is no in-built
disinfection concentration measurement, the
User has responsibility for taking a sample from
the EWD’s diluted disinfectant tank. This test
should be undertaken outside the EWD.
19.10 The automated system or the User test
should indicate an unsuitable disinfectant
concentration for dilution (c) and a satisfactory
disinfectant concentration for dilution (a).

20 M
 icrobiological and temperature tests of
disinfection efficacy
20.1 Disinfection efficacy should be verified
during type testing using the test described in
BS EN ISO 15883-4, clause 6.12.6.2. The test
should not be carried out until the adequacy of
the EWD self-disinfection cycle has been
established.
20.2 If temperature forms part of the
disinfection process, the thermometric test for
assessment of temperature control throughout
the disinfection stage should be completed
satisfactorily before commencing
microbiological tests as described in BS EN ISO
15883-4, clause 6.9.
Disinfection efficacy
20.3 Disinfection efficacy should have been
tested during type-testing with a surrogate
device (BS EN ISO 15883-4, clause 6.12.6).
When necessary the adequacy of the
disinfection process may be verified by using
the method given below, which is included to
provide additional information should
disinfection problems occur.
Endoscope lumen sampling
20.4 The endoscope should be brushed
through with a sterile disposable long-stemmed
cleaning brush after processing. The brush end
should be aseptically cut from the stem and
aseptically transferred to 10 mL of sterile
peptone water containing 0.05% polysorbate 80
and ultrasonicated at between 30 and 50 kHz
for 10 minutes. The eluate should then be
filtered through a 47 mm diameter 0.45 m filter
20 Microbiological and temperature tests of disinfection efficacy
and then the filter placed onto a R2A agar plate
and incubated at 30±2°C for up to five days.
The number of colony forming units (cfu)
counted will give an indication of the adequacy
of the disinfection process.
20.5 A result of less than 10 cfu per brush
sample should be obtained if the endoscope
has been satisfactorily disinfected
20.6 This is the preferred method of lumen
sampling. An additional less satisfactory test
that may be useful to measure the
microbiological performance of the EWD cycle,
manual cleaning and possibly the drying
cabinets is to examine an endoscope after it
has been used, decontaminated and dried. The
test involves passing liquid down the
endoscope lumens, collecting the effluent and
subjecting it to bacteriological counting.
20.7 The following apparatus is necessary:
• sterile water;
• sterile 10 mL syringe;
• sterile collection bottles;
• lengths of sterile tube to connect the
syringe to each endoscope port in turn;
• sterile gloves.
20.8 A suitable procedure is the following (use
of sterile gloves and aseptic techniques are
essential to obtain good results):
43
Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part E – Testing methods
Biopsy lumen:
a. Attach a length of sterile tube of suitable
diameter to a syringe and the other end
to the biopsy lumen port.
b. Flush 10 mL of water down the lumen
and collect into a sterile sample bottle at
the distal end.
Suction lumen:
a. Attach a length of sterile tube of suitable
diameter to a syringe and the other end
to the suction port on the light guide
connector.
b. Depress the biopsy/suction feed button
(red trumpet valve on the control box)
and flush 10 mL of water the entire
length of the suction lumen.
c. Collect the liquid expressed from the
distal end of the endoscope into a sterile
sample bottle.
Air lumen
a. Attach a length of sterile tube of suitable
diameter to a syringe and the other end
to the air inlet port on the light guide
connector.
b. Cover the water port (blue trumpet valve
on the control box) and the water lumen
on the light guide connector with a finger
44
while flushing the water along the air
lumen.
c. Collect the liquid expressed from the
distal end of the endoscope into a sterile
sample bottle.
Water lumen
a. Attach a length of sterile tube of suitable
diameter to a syringe and the other end
to the water inlet on the light guide
connector.
b. Depress the air/water trumpet valve
(blue) on the control box and cover the
air lumen on the light guide connector
with a finger while flushing the water
along the water lumen.
c. Collect the liquid expressed from the
distal end of the endoscope into a sterile
sample bottle.
20.9 In a microbiology laboratory, examine the
chilled samples collected within four hours of
collection if stored at room temperature, or
within 24 hours if stored at 2– 5°C. Carry out a
total bacterial count/mL on each sample using
R2A (BS EN ISO 15883-1 Annex D), TSA or
YEA media and incubation at 30±2°C for up to
five days.
20.10 The results should be below 10 cfu/100
mL as detailed in Table 1 of Chapter 6, ‘Water
system’.
 References

References

BS EN ISO 15883-4. BS EN ISO 15883-1.

COSHH Regulations. BS EN ISO 4788.

Health Technical Memorandum 04-01 Part A. BS EN ISO 3746.

Health Technical Memorandum 04-01 Part B. ISO/TS 15883-5.

Willis, C. (2006). “Bacteria-free endoscopy rinse

water – a realistic aim?” Epidemiology and
Infection. Vol. 134 No. 2, pp. 279–284.

45