DECONTAMINATION
non-enzymatic detergents can be used across wider temperature ranges and are also less allergenic, but enzymatic detergents are more effective cleaning agents and are designed to maximise the removal of residues. Enzymes are proteins that accelerate the rate of a chemical reaction. The enzymes break down large molecules, like fats and blood proteins, into smaller ones. Their superior cleaning power gives enzymatic detergents a significant advantage over non-enzymatic ones, which is of significance when infection prevention is at a premium. The recommended personal protection procedures for staff handling enzymatic detergents are likely to be standard practice in most hospitals, whatever detergent or disinfectant is being used.
When selecting a detergent, it must be compatible with the disinfectant used. This is because during the cleaning cycle there will be low level residue from the detergent which can neutralise the active ingredient in certain disinfectants thereby reducing the microbial killing properties of the disinfectant. Some newer generation detergents like thermosept X-tra are slightly alkaline therefore less likely to damage sensitive instruments, but also contain enzymes to enhance cleaning performance. These ‘new generation’ detergents aid the removal of proteins, and are likely to be more effective than using a neutral detergent.
Switching to a different disinfectant/detergent
Advice should be obtained from both the chemical and WD manufacturers before any changes are introduced. If it is decided to use different chemicals in the WD, care should be taken that the new chemicals do not react with the previous detergent or disinfectant residue. HTM 01-06 advises that the WD manufacturer type-test the proposed chemicals to determine their efficacy and the best settings of the WD control system during type-testing. Factors to consider in terms of the new chemical include efficacy, material compatibility, concentration, stability, storage life, water quality and inclusion of corrosion inhibitors. Care should be taken to ensure that all detergents are compatible with the WD and are employed at the correct temperature and concentration. Detergents and disinfectants must be compatible with each other. These chemicals should be type tested to show compatibility with both the WD and the endoscope.8
If a decontamination unit plans to change detergents and/or disinfectants, there are a number of steps to consider in terms of the switch process. According to a position statement from the European Society of Gastrointestinal Endoscopy (ESGE), 2018: l The user should consult the persons/
OCTOBER 2020
department responsible for infection control and occupational health, as well as the relevant personnel of the clinical service provider.
l Manufacturers of endoscopes, EWDs, and process chemicals must provide compatibility evidence.
l Any necessity for requalification of the reprocessing procedure/EWD must be clarified.
l Staff must be trained in the changed reprocessing procedure taking into account the new products.2
In addition, according to HTM01-06 (Part C, 4.7), if the chemicals used in the EWD are changed, care should be taken that the new chemicals do not react with traces or deposits of the previous detergent or disinfectant. Advice should be obtained from both chemical and EWD manufacturers before any changes are introduced.
Conclusion
COVID-19 has dramatically changed the delivery of healthcare but, as a form of ‘new normality’ returns, SSDs and decontamination units will start to see increased demand predicted to reach higher than pre COVID-19 levels to enable the reduction in patient waiting times. There has been a significant reduction in patients attending GP practices during this time. This has led to concerns that a significant number of patients will have a previously undiagnosed condition causing a delay to treatment and a potential negative impact on outcomes. There will be a major focus on adhering to the highest possible standards of infection prevention and control. Disinfectant and detergent selection will play a key role but the temptation to use harsher chemicals should be resisted and a careful balance found between efficacy and material compatibility.
CSJ
References 1 British Society of Gastroenterology guidance on recommencing gastrointestinal endoscopy in the deceleration and early recovery phases of COVID-19 pandemic, June 2020
2 Beilenhoff Ulrike et al. Reprocessing in GI endoscopy: ESGE–ESGENA Position Statement – Update 2018. Endoscopy 2018; 50
3 Rauwers AW, et al. High prevalence rate of digestive tract bacteria in duodenoscopes: a nationwide study, Gut 2018;67:1637–1645. doi:10.1136/ gutjnl-2017-315082
4 Dancer SJ, et al., Surgical site infections linked to contaminated surgical instruments, Journal of Hospital Infection (2012), doi:10.1016/j. jhin.2012.04.023
5 van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med. 2020 Mar 17 [Epub ahead of print].
6 Zhang Yafei et al. 2019, CoV infection prevention and control in digestive endoscopy, Endoscopy
2020; 52: 312–314
7 Public Health England, COVID-19: infection prevention and control guidance, June 2020
8 BSG Guidance for Decontamination of Equipment for Gastrointestinal Endoscopy, The Report of a Working Party of the British Society of Gastroenterology Endoscopy Committee, March 2014, Revised November 2016
9 Geller, C., Varbanov M., Duval, R.E. Human Coronaviruses: Insights into Environmental Resistance and Its Influence on the Development of New Antiseptic Strategies; Viruses 2012, 4, 3044- 3068
10 Rutala WA, Weber DJ. Disinfection, sterilization, and antisepsis: An overview. Am J Infect Control. 2016;44(5 Suppl):e1-e6. doi:10.1016/j. ajic.2015.10.038
11 Department of Health, Health Technical Memorandum 01-06: Decontamination of flexible endoscopes: Part C – Operational management, March 2016
12 Department of Health, HTM 01-01: Management and decontamination of surgical instruments: Part D – Washer-disinfectors, July 2016
13 Department of Health, Operating framework for urgent and planned services in hospital settings during COVID-19, May 2020
14 JAG Endoscopy, Principles for restoration of endoscopy services following the COVID-19 pandemic, 30 April 2020
15
www.thejag.org.uk/COVID-19 accessed 23rd June 2020
16 Royal College of Surgeons, Recovery of surgical services during and after COVID-19, May 2020
About the author
Trevor Garcia MIDSc (Chtd), a decontamination consultant at TG Decon Consultancy, was previously the decontamination manager at Surrey and Sussex Healthcare NHS Trust (from 2003 to 2019) until he retired. He has also occupied the role of director of education at the IDSc, where he was instrumental in developing a programme of professional qualifications to develop the skills and knowledge of decontamination practitioners. He is also the Chair of IDSc Central and Southern Branch, and secretary of the Sterile Services Business Group (SSGBi).
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