INFECTION PREVENTION AND CONTROL “This is a miniscule amount required


for transmission, but the 5 µg [in the aforementioned HTM 01-01] gives us many hundreds of doses,” he commented. Standard BS EN 15883 states it should be less than 6.4 µg per cm2


.


Jim Tinsdeall pointed out that, given the incubation period of 1-42 years, it is difficult to learn from incidents which might otherwise prompt efforts to change practices. Departments often say they are ‘following manufacturers’ instructions’, but it is the processor that is accountable and responsible for ensuring the desired result. Therefore, they must carry out tests to prove the required levels of decontamination have been achieved. There are conflicting messages around testing methods, however. HTM 01-01 refers to measuring ‘directly on the surface, rather than by swabbing or elution’, while the standard BS EN ISO 15883-1 2009 refers to the ‘Biuret method (swabbing), or ortho-phthalic-acid-dialdehyde OPD (elution) or Ninhydrin’. The speaker stated that testing is a case of ‘horses for courses’, depending on the design challenges of the instrument, and he went on to show some slides of some difficult-to-clean instruments. In some cases, neither ‘measuring directly on the surface’ or ‘swabbing’ would give an accurate indication of protein located in the hard to access areas; elution in a lab might be the best option in such cases, and the lab may need to disassemble the instrument. He highlighted some test results on


‘remote working surgical instruments’, which led to some improvements. By keeping the instruments moist and speeding up the process (by removing transport delays), the protein residues were reduced to a quarter of the levels detected prior to the changes. “If we don’t test and we don’t know, we


are just blindly carrying on,” he asserted. While keeping instruments moist will improve protein removal, who is responsible for monitoring this? Sterile services departments often see variations in practices – some instruments will arrive at the SSD properly bagged and sprayed, to keep them kept moist, while others arrive simply wrapped in paper, and are allowed to dry out. Automation is also important – ideally,


we should aim to move away from manual processes, such as brushing, to the flushing of lumens. “The problem with manual processes, is


that we all have off days,” he commented. Jim Tinsdeall also suggested that Sterile


services departments should double process devices where inspection is not possible – this may include manual, ultrasonic, or connection to lumens in the washer-disinfector. It is important to quantify the residual protein, using the best methods available, and departments


36 Health Estate Journal May 2024


Given the potential risks around prions, removal of proteins on medical devices is an important area of focus.


should ‘review, revise, and improve’. If resolution is not possible, this should be included on the Risk Register.


Infection risks and laundry The afternoon session looked at the risks associated with laundry decontamination. Karren Staniforth, from the UK Health Security Agency, shared her findings and observations from investigations into outbreaks across the UK. She highlighted the risk of contamination to people handling the laundry, and the risks of patients acquiring infection from re-contaminated laundry, citing a range of literature as evidence that these acquisitions occur. Among the literature was an


investigation into an outbreak of mucormycosis in a paediatric oncology unit – linked to water damage arising in a linen store, located adjacent to the parent’s shower room (Garnet et al, 2008). This demonstrates how poorly maintained laundry storage rooms can pose a potential risk. However, recontamination of laundry can also occur due to contact with laundry staff with skin or enteric infections and poor practice. Other routes for contamination include laundry floors, roll cages, and vans, when there is a failure to follow cleaning and handling procedures, which prevent recontamination. There is also a risk arising from


decontamination failures. Linen may appear clean, but the microbial load may remain high if thermal disinfection has not been reached. Temperature and contact times need to be achieved consistently, and laundry decontamination should be a quality assured process. Changing the load (without re-validation), or pausing and restarting the continuous batch washer (CBW) after it has cooled, can cause failure, but these may go undetected and unreported. Karren Staniforth pointed out that spore


forming bacteria such as Bacillus cereus and Clostridioides difficile will survive disinfection (e.g. 71 °C for three minutes). Spores are removed by mechanical


action and dilution, but if contamination is high, a significant number of potentially infectious spores can remain attached to linen. This is particularly a problem when bacterial contaminates replicate during transportation of used linen, during the warmer summer months. She concluded that:


n Bacillus cereus is implicated in 57% of all laundry-related outbreaks of infection.


n Cases and outbreaks may be undetected and unreported.


n It is easier to maintain control than to reduce counts once control has been lost.


n Active laundry testing is recommended during summer months.


n Total blood culture isolates can easily be monitored throughout the year.


n Simply increasing the rinse-water volume may not be sufficient to regain control, and excess water may have a negative impact on mechanical action.


n More research, guidance, support, and training, would be useful in preventing and managing these outbreaks and incidents.


It was evident, from Karren Staniforth’s presentation, that laundry validation is not as robust as reusable medical devices, and this is an area of decontamination that requires improvement for the future. A detailed insight into the standards and HTM guidance for laundry decontamination followed, by Wayne Spencer, a Consultant from Spencer Nickson. He pointed out that one of the reasons for the introduction of HTM 01-04 was the fact that the segregation of foul and infected linen was not working. In reality, large amounts of water-soluble bags are opened by staff and then discarded as waste; staff are having to open the water-soluble bags manually, as the continuous tunnel washer (CTW) struggles to process them in large volumes; and most laundries are pre-sorting linen – including infectious linen. Wayne Spencer discussed the way forward to achieving ‘a safer future’, which


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