STERILE SERVICES
that gave safety issues to patients, Graham explained how AE(D) were used to solve the problems: “I was called in when a Trust’s washers weren’t heating up. There was a remote HSDU, the building was self contained away from the main hospital and, after discovering a lack of maintenance and care, we ripped it all out. The HSDU manager closed the doors and told theatres he was shut! “Another example, involved the discovery of black ‘bits’ on cardiac instruments in theatre – pin-head sized pieces of blood. This went on for nine weeks and the problem took weeks to resolve. The SSD manager removed blood found in trays. The result? Changed methods, equipment and a process was introduced to educate all involved.” Summarising what exactly is expected from an AE(D), Graham concluded: “Always maintain a good understanding of processes involved. Be a good listener and investigate, as required, all aspects of the process. It’s vital that you admit any areas of knowledge where you need to find advice yourself, and to use institute supported CPD activities.”
What you see is what you get, but is it fit for purpose?
Paul Anderson, regional operations manager at Steris Instrument Management Services described the lessons learned following incidents of instrument staining at a Trust. A new instrument had been purchased from a single supplier, but theatre staff quickly
noticed staining on the device, resulting in an investigation which took six months. “Rusting, and pitting around the branding areas were visible on the instruments,” Paul explained. “We looked at issues such as the supply and manufacturing processes, as well as maintenance, protein and storage. “The impact of this was hypervigilance by theatre staff, who were using magnifying glasses to report more and more stains. The Director of Infection Prevention and Control (DIPC) and Public Health England (PHE) advised ceasing all non-urgent procedures – but this was not really an option. We carved out microbiological analysis and found that the stains were likely from packaging –
however, I believe this may have been a sampling error. “The DIPC reviewed HAI rates for a 60 month period and noted no change, before or since the introduction of the equipment. Metallurgical analysis confirmed the source metals were of the correct grade (420 martensitic stainless steel) and no staining was reported, so this meant something was occurring post-sterilisation. Potential causes were the laser etched instruments and the use of saline in some areas. A number of old trays were widely used at this Trust – and these were replaced with stainless steel DIN, The issue has not been reported since.” According to Paul, this may not be a localised issue, but it was decided that it wasn’t unsafe for patients: “Instruments that were once acceptable, are now deemed poorly designed,” he continued. “Images depicted dips and coatings issues, rongeurs with complex matted surfaces and can’t be taken apart for cleaning – and one instrument that the manufacturer said shouldn’t be taken apart for cleaning – we did so and discovered an unacceptable amount of organic material. Following Paul Anderson’s talk, Peter
Hoffman, Public Health England, explored the links between incident assessment and patient risks.
“My experience is via two main routes,”
he began. “Firstly, input into guidelines and standards – and secondly, advising as an individual, or as part of a group. My role is to investigate and advise on suspected outbreaks and assess decontamination failures with regard to subsequent advising. “These always start from a point of comparable chaos – a point of early suspicion with few established facts. Outbreaks are different. When two or more patients are contaminated by the same microbes, evidence is often poor. Generally it’s possible to observe what happened at a microscopic level at an unknown time/times in the past.”
Human performance within a given clinical system, and factors that can influence people and their behaviour, mean that human error is
not absolutely preventable. Martin Kiernan, Richard Wells Research Centre, University of West London.
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Listing infectious agents, Peter described the effects and risks: “Bacterial spores are highly resistant to inactivation,” he warned. “However, most are non-pathogenic. Vegetative bacteria of human or animal origin, in hospitals mean patients are very susceptible to inactivation – and these can be highly pathogenic. Vegetative bacteria of environmental origin, of which a few have some pathogenicity, are very susceptible to inactivation, while fungi/ yeasts have a similar pattern to bacteria – primarily for patients who are susceptible. “Viruses are the ultimate parasite.
Very susceptible to inactivation (even hepatitis B or C), and all human viruses will infect humans. Prions, too are very resistant and probably very pathogenic.” Focusing on steam sterilisation, Peter noted that when specific microbes are exposed to lethal conditions, not all will die at the same time. He described two approaches to sterilisation: Bespoke
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