STERILE SERVICES
Lessons learned in decontamination
The Central Sterilising Club Autumn Study Day 2018 provided an excellent learning opportunity for all those involved in decontamination – from hands-on operatives, decontamination managers, infection prevention practitioners and associated professionals to extend their knowledge and improve practice.
Taking place on 17 September 2018 at the striking Birmingham Botanical Gardens, delegates were welcomed by Val O’Brien, CSC Chair, who provided an overview of this year’s theme “What could possibly go wrong?” The first session, chaired by Gill Ellis-Pow, examined whether surgical instruments can always be considered fit for purpose. Sharon Fox, Trust decontamination and sterile service manager, University Hospitals Birmingham NHS Foundation Trust, described a case in which black particles were discovered on a number of refurbished trays.
Theatre staff had reported high levels of
particles which were only visible when lifting instrumentation and metallurgy tests were performed, enabling the samples to be sent to Birmingham University. The majority revealed traces of FE (iron) and SI (Silica). Sharon Fox produced a VCI Laminectomy – Cause & Effect diagram, which showed the process flow and revealed what the main problems were. “All the laminectomy trays had problems,” she explained. “The refurbishment of the trays was what caused the black particles, and so all newly refurbished trays are now pre-treated in ultrasonic and processed three times through the washer disinfector. This seems to have worked.” Citing another case, Sharon described an incident in an ophthalmic theatre where particles were discovered in a patient’s eye, following a small incision in the eye to remove a cataract. “In December 2014, plastic particles were found in a patient’s eye,” she said. “However, when a second incident occurred later that month, all trays were removed from circulation and reprocessed. “During this time, all SOPs,
manufacturers and maintenance procedures were reviewed, but then a third incident occurred and surgery was suspended. “Theatres weren’t holding stock as per manufacturers’ guidelines, so we looked at training, used another lab and the result was the IA Tip. The IA tip was fitted to the IAP, but
NOVEMBER 2018
It’s vital that you admit any areas of knowledge where you need to find advice yourself, and to use institute supported CPD
activities. Graham Stanton, IHEEM AE(D) Registration Board
when theatre staff removed the plastic sheath, it shed plastic particles and into the patients’ eyes. We reviewed training – and this is ongoing. We also improved SOP within theatres; reviewed lumen thermal disinfections and reported the data to the MHRA.” Graham Stanton, retired senior decontamination engineer, Shared Services, and currently chair of IHEEM AE(D) Registration Board, took to the stage to discuss difficult situations that involved the AE(D) to try and resolve.
“What do you expect from your AE(D)?” he asked. “It is a complex role that requires a good effective team working with other health professionals and this is essential to be effective for patient safety with regards to decontamination.”
Sharing his experience in situations
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