Central Sterilising Club
use and sustainability, it is possible to develop a simple system that is a ‘familiar design, fully reusable and interchangeable with other instruments’.
The Alzheimer’s question and lumened devices Jim Tinsdeall went on to consider the decontamination risks in relation to Alzheimer’s and lumened devices. Jim has contributed his knowledge as a Head of Estates within the NHS for 20 years and is now running a limited company providing AE(D) services and consultancy to healthcare organisations in the UK and EU. He opened his session with discussion of the evidence linking transmission of Alzheimer’s to patients who had growth hormone back in the 1980s. “Lumened devices are an area that we need
to look at to see if we can do better,” he warned, presenting a slide depicting the inside of a lumened instrument that had been reprocessed but clearly showing congealed blood inside. “My personal view is that this can happen at virtually every SSD.” Banerjee et al, published a paper titled:
‘Iatrogenic Alzheimer’s disease in recipients of cadaveric pituitary-derived growth hormone, in October 2023’.2 The researchers stated: “We now provide
evidence that Alzheimer’s disease is also transmissible in certain circumstances and, therefore, that Alzheimer’s disease (like Aβ-CAA) has the full triad of etiologies (sporadic, inherited and rare acquired forms) characteristic of conventional prion diseases. This should further emphasise that the principles of prion biology have relevance for other neurodegenerative diseases involving the accumulation of diverse assemblies of misfolded host proteins, which may have propagating and neurotoxic forms.” Furthermore, they concluded: “The
symptomatic cases that we report here are consistent with that conclusion and should prompt both further consideration of public health implications and the primary prevention of iatrogenic Alzheimer’s disease — for example, by ensuring effective decontamination of surgical instruments.” Jim pointed out that the numbers involved are
of even greater concern: “Statistically, there are a very few people with CJD, but there are a lot of people – particularly over the age of 65 – who have Alzheimer’s or dementia,” he commented. So, why is it difficult to tackle Alzheimer’s and
CJD? Jim explained that misfolded amyloid-β peptides and hyperphosphorylated tau proteins are associated with Alzheimer’s, while misfolded prion proteins are associated with CJD. There is a
lot we don’t know, and it has a “40-year feedback loop” which makes it challenging. In addition, prion protein is very resistant to heat. We can practically test for protein but not affected protein.
In 2020, there were 131 recorded deaths from
sporadic CJD in the UK. Variant CJD (vCJD) is likely to be caused by consuming meat from a cow that had bovine spongiform encephalopathy (BSE or ‘mad cow’s disease), a similar prion disease to CJD. In 2020, there were no recorded deaths from vCJD in the UK. In 2020, there were six deaths from familial
CJD and similar inherited prion diseases in the UK. In 2020, there was one death from iatrogenic CJD in the UK caused by receiving human growth hormone before 1985. Jim suggested that each NHS Trust is likely to see a CJD patient from one year to the next, so occurrence is coming on to site.
However, there has been some progress in
how we manage the risks in sterile services. Since the 1980s, various methods of testing have been developed – such as the ProReveal and swabbing mechanisms. We have increased the amount of ultrasonics that are available, eliminated the use of stainless-steel brushes, introduced excellent track and trace options, washers have advanced with connections for every lumened device, there are excellent detergents, independent monitoring, centralised decontamination, as well as guidance, standards and the law. Jim commented that “if you want to tightly
control standards, you must have fewer areas carrying out decontamination, so you have fewer people to train and oversee.” If you have 50 areas reprocessing devices – instead of just two (i.e. the SSD and endoscope decontamination unit) – some of those areas are “not going to be as good as you want,” he warned. There are still some basics that we need to focus on, such as the time between use and wash. “The sooner we can get the device into the decontamination unit and washed, the better,”
he explained. He gave an example of leaving porridge oats in a bowl to dry, in the morning, then putting the dish in the dishwasher in the evening – the dishwasher will only remove around a third of the dried on porridge. Even if you soak the dish for a couple of hours to remove it, this all takes time. In short, the quicker we can get it washed, the easier it is to remove it – and, if you can’t get it washed straight away, you will need to keep it moist. However, Jim warned that we also have to think about corrosion – he pointed out that many surgeries use saline, which increases the likelihood of corrosion, leading to surfaces that are more likely to allow soil to bind.
Risk and human factors Jim added that automation is an essential quality requirement. “If we are doing a repetitive manual task that requires concentration and intricacies, how good are we?” he questioned. He pointed out that a competent decontamination professional might produce good work 90% of the time, but what about the 10%? Everyone has ‘off days’ when they are tired or distracted. “A machine will do it time and time again –
consistently. Staff training is key, but all too often staff do not understand the reasons why they are doing something. We need to treat staff with respect and dignity instead of just telling them to do it. Communication is vital – there is a tendency to blame the reprocessor, or blame the manufacturer, but we need to work together,” he commented. Jim said that there is a drive to return to
reusable – providing it is possible and safe – but we need to keep reprocessing as central as possible. Localised decontamination wasn’t satisfactory, historically, hence the move to single use. While a shift to reusable with central processing may be an option, “we need to think carefully before we say ‘yes’ and throw all the single use away”, he asserted. “Where is it going to get reprocessed and is it acceptable?” he
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