Review for 10.1186/1471-230X-11-105 (2011)

Reviewer's report
Title:Comparative cost-efficiency of EVOTECH ECR versus Medivator DSD-201
in a real-world Canadian hospital endoscopy setting.
Version: 2Date:14 February 2011
Reviewer: Michelle Alfa
Reviewer's report:
This is a clearly written manuscript that addresses very practical aspects of using
the EVOTECH or Medivator automated endoscope reprocessors (AERs). The
data is useful and will be of great interest to healthcare facilities, however, there
are a few issues that need to be clarified (as outlined below).
Major compulsory Revisions:
1. Methods:
It is unclear in the methods section if the Medivator DSD-201 had an automated
cleaning cycle that was routinely used in addition to the required manual
cleaning. From the supplies listing in Table 5 it would appear that there was a
cleaning cycle that was part of the Medivator DSD-201 process since there was
detergent costs listed. The following need clarification in the manuscript:
- The cycle parameters of the EVOTECH and the Medivator AERs that were
used should be clearly stated.
- The authors should clarify that each scope is run in a separate basin for both
the EVOTECH and the Medivator units evaluated.
- The authors should also indicate if the cleaning cycle in the Medivator DSD-201
is optional.
If the cleaning cylce in the Medivator was NOT used and only the manual
cleaning was done - what would be the time impact?
2. Table 1: It is unclear from the steps outlined whether the scopes that are
manually cleaned were rinsed with tap water after the enzymatic detergent step
or not? It seems they were immersed in enzymatic, brushed three times and then
enzymatic detergent was flushed through the channels using the automated
flushing pumps. However it does not indicate that the scope was then flushed
with tap water prior to placing into the Medivator. The North American guidelines
for reprocessing of flexible endoscopes all indicate that for manual cleaning there
should be immersion in enzymatic detergent, brushing and flushing of the
channels and external cleaning of the scope while immersed in the enzymatic
detergent. This should be followed by immersion in tap water with channel
flushing with tap water prior to performing HLD. The authors need to clarify what
the sequence of steps were for the cleaning process that was used. If the manual
rinsing with tap water was omitted bacause the scope was being placed in the
Medivator that would then use the cleaning cycle this should be clarified. It
should be noted that the tap water rinse is an important part of the manual
cleaning process that should not be omitted for AERs that require manual
cleaning because if the endoscope sits for any length of time before being placed
into an automated endoscope reprocessor, the enzyme cleaning solution
(enzymes are proteins) will dry on the outside of the scope and may create a
"film" on the lenses etc that may be difficult to subsequently remove.
3. Table 3 and Table 7: Currently the difference between the Medisafe and
Evotech labour requirements range from 1.54 mins for bronchoscopes to a
maximum of 2.61 mins for colonoscopes. However, these times are based on
manual cleaning that does not appear to include a tap water rinse (as per steps
outlined in Table 1). As such the time differential for labour would certainly be
highter if the required manual tap water rinse was included. The authors should
include what the time differential would be if the manual cleaning included the
labour required to transfer of the scope from enzymatic to perform a thorough tap
water rinse of the external surfaces and all the channels. This also needs to be
taken into consideration in Table 4 as the data as presented do not include the
labour required for the tap water rinse in the manual cleaning process.
4. In Table 4 and in the discussion there is no consideration given to concurrent
processing of two scopes at the same time in the Medivator and Evotech units.
The average daily reprocessing times given in Table 4 give the impression that
the total daily time savings for reprocessing of all scopes would be 6.2 hours.
However, what has not been accounted for is that most times two scopes are run
concurrentally in each AER so the actual saved time would be more like 3.1
hours of actual clinic time. They should be able to determine what percentage of
scopes get run concurrently (i.e. two scopes run in the AER at the same time)
versus the percentage of scopes that get run sequentially. This would give a
more meaningful estimated of actual time savings per clinic day.
Table 5: For the Medivator, Cidex OPA cost is listed. In addition, there is a listing
for "Cidex OPA in ultrasonic" as well as "CIDEX". It is unclear what these last two
represent or where in the Medivator cycle they are used. THe authors should
clarify at what point in the scope reprocessing cycle these are used or whether
they are used for decontamination of the Medivator itself??
Table 5: It is unclear how what the "Blue wipes" and "Blue wraps" are used for?
The authors should clarify if these are used in the manual cleaning process??
Minor Essential Revisions:
1. Table 4 title: Currently it states "annual" in the title, but there is not data given
for annual reprocessing or labour times. The word "annual" should be omitted
from the title.
Level of interest: An article of importance in its field
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
In the past five years I have been an invited speaker at conferences etc where
travel, accomodation and speaker fees have been sponsored by J&J. I am the
recipient of a research contract from J&J that was used to evaluated the cleaning
efficacy of the EVOTECH unit. I did not personally receive any monies from this
research contract. I do not have stocks or shares and do not stand to gain or lose
financially from the publication of this paper now or in the future. I have never
received a salary from this company and do not have any other financial or
non-financial competing interests in relation to this paper.