Decontamination: the challenges ahead in 2022
What are the hot topics for the decontamination sector in 2022? Top decontamination experts provide their views on the challenges and opportunities ahead.
Department of Health figures show a record 6 million patients waiting for planned treatment, while waiting time statistics also show that the number of patients waiting over two years for hospital treatment (12,491) passed the milestone of 10,000, for the first time. There has been a great deal of discussion around the need for surgical hubs and operating theatre strategies to tackle the backlog, but what will this mean for decontamination teams across the UK, in the coming year?
Surgical and endoscopy teams depend on decontamination services to provide quick and efficient turnaround of reprocessed medical devices, but the pressure is set to intensify in 2022, as Jimmy Walker, the chair of the Central Sterilising Club (CSC), points out.
“There is no doubt that there will be an increase in productivity and decontamination units are going to be extremely busy. The NHS will have to work very hard to clear the backlog of operations and, for some decontamination facilities, this could prove to be an ‘eight-day’ exercise,” he commented.
During the pandemic, many decontamination staff were transferred to other areas, but these staff will now be needed to meet the increased demand for decontamination of medical devices. Ensuring staff are competent and back up to speed will be an important aspect of the recovery.
“There was already a shortage of qualified and skilled staff in decontamination. However, we need to consider each stage of the work and establish where the gaps are,” Walker continued. He added that training will be crucial to ensure high quality services, as we move forward, and it is important that this is not overlooked as the workload ramps up
“We need to make sure that staff feel confident in their qualifications, confident in their training and confident in performing their day-to-day work. This requires an effective strategy, ensuring that the education is in place to support them,” he commented.
CSC, working with other organisations – including the Institute of Decontamination Sciences (IDSc), Infection Prevention Society (IPS), Hospital Infection Society (HIS) and British Society of Gastroenterology (BSG) – will have a key role to play in the provision of training and educational opportunities, as well as the development of guidance.
CSC will also continue to support decontamination professionals by awarding grants to fund training or attendance at educational events. Going forward, it will be important to ensure staff maintain their CPD training, if we are to rise to the challenges ahead.
Education and study days
Despite the impact of the pandemic, CSC has continued to host study days online and has now started to return to face-toface study days and scientific meetings, to support staff with vital education. This has enabled decontamination professionals to stay informed of what is happening in the industry – from changes in standards and advances in technology, to identifying issues around patient and staff safety.
Are we missing failures?
One topic that remains high on the agenda is the importance of identifying decontamination failures. Technologies that help staff inspect, report and trace will be key to protecting patients. While the new threat of COVID-19 has been taking centre stage, familiar foes such as Pseudomonas aeruginosa and vCJD continue to present challenges. Speaking at CSC’s 2021 Autumn Study Day, David Jenkins, from University Hospitals of Leicester NHS Trust, delivered a presentation on ‘How do you know if you have had a decontamination failure?’ He highlighted a case of a patient who has undergone cystoscopy in 2019 and subsequently presented with a urinary tract infection from which P. aeruginosa was isolated. In 2020, the patient went on to present with a knee infection which also grew P. aeruginosa. A few days later a P. aeruginosa positive bloodculture was also detected in a patient who had also had a cystoscopy. All isolates were sensitive to antibiotics and the VNTR profiles identified that both strains were similar and that there may have been a common source. All the cystoscopes had been decontaminated in the same unit. The rinse water was clear. However, additional patients started to be identified as being positive with P. aeruginosa – all with a similar VNTR profile. The cystoscopes were flushed and irrigated as were the three-way taps (to enable irrigation). Manufacturer’s instructions were to decontaminate the three-way valves using either glutaraldehyde, ethylene oxide or steam sterilisation, none of which were used. Instead, the three-way valves were placed in the decontamination tray and processed through the endoscope washer disinfector.
Microbiological analysis identified the three-way tap as being contaminated and a number of different strains of P. aeruginosa were recovered. The outbreak involved 14 patients over a period of eight months. While the rate of infection was relatively low, Jenkins warned that we may be missing many outbreaks associated with endoscopy and highlighted the need for systems to be put in place to identify adverse patient outcomes that could be associated with reusable medical devices. The case review highlights the ongoing importance of track and trace, using electronic patient records, as well as the need to review practices across hospitals to ensure safe decontamination of cystoscopes.
CJD: risks for patients and staff?
Vigilance around the risks of CreutzfeldtJakob Disease (CJD) must also be sustained, as Katy Sinka, Public Health England, pointed out, during her presentation at the CSC Autumn Study Day. In the UK, key policies remain in place to prevent the transmission of vCJD via blood and surgery (quarantine or disposal of instruments used on known cases; introduction of disposable instruments where appropriate, and provision of clean and non-infectious re-usable surgical instruments).
She pointed out that the NICE IPG 666 guidance was updated in 2020 and deals with surgery involving the high-risk tissues. The updated guidance emphasises the need for instruments to be kept moist to aid the removal of proteins before cleaning and sterilisation and removed the need to retain separate sets of neuroendoscopes or reusable surgical instruments used on high risk tissues for people born after 1996.
However, a sobering development has been the report that a French laboratory researcher died in 2019 from vCJD, which was acquired seven and a half years earlier in a laboratory incident involving a puncture wound during a procedure. In 2021, there were reports of the tragic death of a second laboratory worker in France who contracted vCJD via occupational exposure. As a consequence, France has since introduced a moratorium on prion research.
Also following the reports in Europe of the incidents of transmission of vCJD, involving laboratory workers, guidance has been updated for those handling 1) high risk tissues that contain high concentrations of PrP prions that need to be managed in specialised laboratories; 2) low risk biofluids from patients suspected to have CJD with no or very low concentrations of PrP prions managed in high throughput laboratories. There are now also considerations for laboratory work involving other proteopathic seeds such as those in Alzheimer’s disease where there is a theoretical risk of exposure.
Decontamination engineering: skills gaps?
At CSC’s Autumn Study Day, John Prendergast, AE(D), the senior decontamination engineer at NHS Wales, highlighted the fact decontamination equipment has become increasingly complex. This equipment requires maintenance and validation to precise standards, yet the sector faces significant skill shortages. There is significant variance in the standards of engineers appearing within decontamination departments.
According to Prendergast, this may be due to a number of possible issues:
- A lack of training, out of date training or not enough ongoing training (CPD).
- Engineers taking job opportunities outside their skills matrix, often with no apprenticeship to support the basic theories of engineering.
- The training structure within the decontamination industry may not be aligned to current demands and equipment.
- There is a lack of supervision or competency assessment by facility management. Often this is because of lack of an AP(D) or no communication with the AE(D).
- Organisations may be seeking the cheapest solution, without considering quality or consistency of service, as well as changing providers each year, without the thought of consistency or developing the skills from within the organisation.
In general, he pointed out that the engineering industry does not promote technical apprenticeships as it once did. While there has been a drive to address this, in recent years, Prendergast questioned whether this was sufficient to develop the core technical skills required for the decontamination sector. He asked: ‘should the decontamination industry look to develop these skills itself?’
New guidance and manuals
The continued development of guidance will also be vital to help support units in maintaining high standards of infection prevention, and CSC and HIS will be focusing their attention on the quality of rinse water in endoscopy in 2022. New guidance is currently being developed by CSC to address potential knowledge gaps, while helping departments to identify whether they are achieving the required standards. A group has also been established to produce a modern version of the Microbiological Advisory Committee Manual produced many years ago. Representatives from professional bodies overseeing this development include: Val O’Brien CSC, Graham Stanton IHEEM, Brian Kirk IHEEM Technical Platform, Bob Spencer HIS, Gail Lusardi IPS, Mett Smart IDSc, Helen Griffiths BSG, Victoria Daniel PHW, Ruth Collins AfPP and Sarah Marshall JAG.
The old MAC Manual has now been reviewed and agreement has been reached on which topics to use to form the basis of the new training manual. The manual is not intended to duplicate existing standards or guidance documents. However, the target audience is anyone wishing to gain an appreciation of decontamination fundamentals. Keeping text to a minimum, the manual will include images and pictorial methods, including algorithms and flow charts, to support easy reference. The intention is to have the electronic manual as a living document to allow easy amendment and updates as required. The document will be held on the CSC website with hyperlinks on all other professional body websites directing readers to the CSC website. The aim is to have Version 1 available by Summer 2022 and it has also been agreed that the new manual will be dedicated to Tina Bradley, who originally proposed the project
Protecting staff must also be a priority for 2022 – COVID-19 has driven an increased appreciation of the importance of effective ventilation. Airborne infection transmission is not the only threat posed to staff in the decontamination unit, however. John Prendergast, has been collaborating with Malcolm Thomas, the lead author of the HTM 03-01 (2021) guidance on specialised ventilation for healthcare buildings, to develop a CSC document focusing on the decontamination workplace. While this will consider how ventilation can help to reduce the risk of airborne infection transmission, when performing manual cleaning (for example, through aerosol droplets), it will also provide an insight into the protection of staff working in environments where chemicals such as peracetic acid are used – by implementing improvements in ventilation. The final version of the document is expected to be published early in 2022.
Ultimately, 2022 may prove to be a challenging year for decontamination units, with pressure to achieve increased decontamination volumes and faster turnarounds. Patient safety must remain a top priority, despite these pressures, but the safety and wellbeing of decontamination staff must also be given the attention it deserves. Staff will need to be supported as they manage increased workloads and pressure – the mental health and stress levels of teams must be closely monitored by decontamination leads, over the coming year. Time and resources for training must also be made available, to safeguard high standards of patient safety, both now and in the future. COVID-19 has presented sterile services departments with a new threat to focus their attention. But it is evident that some of the old, familiar issues persist – particularly around instrument design. This will require departments to challenge the status quo and to apply pressure on manufacturers to tackle this thorny issue. The sector will need to continue to work closely with industry around R&D, ensuring they put infection prevention and patient safety at the centre of all they do.
For information on the CSC, visit: https://centralsterilisingclub.org
1 Rizan, C, et al, Environmental impact of personal protective equipment distributed for use by health and social care services in England in the first six months of the COVID-19 pandemic, Journal of the Royal Society of Medicine, 16 March 2021, https://doi.org/10.1177/01410768211001583 https://journals.sagepub.com/doi/full/10.1177/ 01410768211001583