INFECTION PREVENTION & CONTROL
to evaluate environmental cleanliness. Common approaches include: n Visual inspection (this has very low sensitivity).
n ATP. n Fluorescence marker. n Microbiology (bacterial or viral culture, or PCR).
By auditing clinical surfaces and equipment, a study by Anderson et al showed that the average relative light units (RLU) cleaned by domestic staff were 64% lower compared with surfaces cleaned by clinical supportive staff. (Equipment was assessed in triplicate against a cleanliness benchmark of 100 relative light units (RLU), using an ATP system.)13
Reprocessing of medical devices Joost Hopman went on to discuss the difficult issue of reprocessing medical devices labelled as ‘single-use’. “This is a non-issue in high resource settings. However, in LMICs, this is happening all the time,” he commented. In India, guidance was issued on the
reuse of cardio-vascular catheters and devices in the form of a consensus document. It stated: ‘In the developing nations of Africa, Eastern Europe, Central America, and South America, although reuse is very common, cleaning and sterilisation of single-use devices is often performed within the hospital, sometimes in an unregulated manner.’ “This happens because they do not
have the resources,” said Joost Hopman. The reuse of single-use medical items is a complex ethical issue that many healthcare providers are faced with, and a paper in the Journal of Medical Ethics added to the discussion. The author stated: ‘The stipulation that a single-use device should never be reused places the healthcare system and society at large in a position of financial hostage to manufacturers.’14 Joost Hopman described this as ‘an
interesting statement’, and added that we need to start discussing this issue, especially in light of the sustainability challenges in high resource settings. The Asia Pacific Society of Infection Control (APSIC) guidelines for disinfection and sterilisation of instruments in healthcare facilities state: n There should be written policies and procedures for reprocessing each type of medical equipment/device, including single-use items.
n There should be a corporate strategy for dealing with single-use and single patient use medical equipment/devices.
n Needles must be single-use, and must not be reprocessed.
n The healthcare setting must have written policies regarding single-use medical equipment/devices.
n Critical and semi-critical medical 40 Health Estate Journal October 2023
“The emphasis has been on hand hygiene, but I believe that cleaning and disinfection is even more important,” said Joost Hopman.
equipment/devices labelled as single use must not be reprocessed and re-used, unless the reprocessing is done by a licensed reprocessor, which is a facility or unit with a legal licence to reprocess single-use items.
n It is strongly recommended that catheters, drains, and other medical equipment/devices with small lumens (excluding endoscopy equipment), be designated single-use, and not be reprocessed and re-used, even if designated as reusable by the manufacturer.
Decontamination of beds Joost Hopman went on to discuss the decontamination of hospital beds, and highlighted a paper on the ‘Effect of surface coating and finish upon the cleanability of bed rails and spread of Staphylococcus aureus’. The study found that in the absence of contaminating soil, bacterial transfer from fingertips to rail ranged from 38% to 64%.16 “In my own hospital, we have a bed
washing machine,” he commented, highlighting a study evaluating the efficacy of mechanical bed cleaning. The study by Joost Hopman and his
colleagues evaluated the training of the domestic service team, as well as the cleaning quality of manual and mechanical regimens. ATP and microbiological contamination were measured in five predetermined locations on all beds. Manual cleaning was introduced over a two-month pilot study at the surgical short-stay unit, and beds from other departments were processed according to the ‘gold standard’ mechanical cleaning. ATP levels were evaluated in three locations on 300 beds after cleaning. The study found that training improved the quality
of cleaning significantly, while mechanical cleaning resulted in significantly lower ATP levels than manual cleaning.17 Joost Hopman also presented the findings of a study examining manual cleaning of hospital mattresses.18
In low-
resource settings, mattresses were highly contaminated, as noted by ATP levels. The study found that routine manual cleaning by trained staff can be as effective in a low-resource setting as in a high-resource setting – the key to success is access to training.
Based on the study findings, Joost Hopman and his colleagues recommended a multi-modal cleaning strategy that consists of training of domestic services staff, availability of adequate time to clean beds between patients, and application of the correct type of cleaning products. Another (multicentre) study by Joost Hopman and colleagues looked at the use of UV-C light disinfection on bacterial contamination of flexible endoscopes without a working channel, within LMICs and high-income settings. The study found that UV-C light disinfection appeared to be more effective in reducing colony forming units [measurements of bacteria] (CFUs) compared with the standard method with the endoscope washer-disinfector. A UV-C device has been developed that enables disinfection of devices in only 25 seconds, which can be used in LMICs. Other developments include Artificial
Intelligence technology to monitor all the movements within a room, which could be used to prevent patients falling by activating lights, for example, but also for IP&C. The technology has the potential to map where surfaces have been touched, and hence would identify surfaces that require cleaning and disinfection. The information can be
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