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.
Software key in a post-COVID era
CSJ asked Brian King, EMEA sales training manager at Cantel Medical: ‘what will be the top transformative decontamination technologies for 2022?’ He believes software – supporting traceability, infection prevention and compliance with guidance – will be vital to ensuring safe recovery of endoscopy services
“Innovations such as software that can track the whole endoscope procedure journey should be considered when reviewing infection control methods. This enables departments to trace all endoscopes, from hygiene status to repairs, location and logged tests. Such systems give decontamination teams full visibility of the endoscope lifecycle. Technologies like this, which focus on the traceability for cleaning and reprocessing endoscopes, will become increasingly important in the effort to enhance infection control measures and make endoscopy services as safe as possible moving forward.
“We are by no means out of the woods with regards to COVID-19, and this will continue to influence how decontamination departments operate in 2022 and beyond. By using the learnings of the last eighteen months, we can ensure patients continue to be kept safe. This will involve focusing on ensuring our understanding of department-specific COVID guidance is up to date, to provide complete confidence that the measures in place will significantly reduce infection risks for patients.”
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.
Increasing demands from robotic surgery
CSJ asked Nicola Thurston, sales and marketing manager, Schülke & Mayr UK, ‘what will be the top decontamination challenges in 2022?’
“For hospital Trusts, one of the main challenges in 2022 is likely to be finding a balance between the constant drive to cut costs, while purchasing decontamination products which work effectively and do not damage equipment or people.
During the pandemic, many new manufacturers of wipes and hand sanitising gels entered the clinical market. Subsequently, some of these products have since been withdrawn from supply. An ABHR was withdrawn from use in Ireland when some batches were found to contain methanol rather than ethanol. A health warning was issued that ‘prolonged use of the product may cause skin problems, eye and respiratory irritation and headaches.
When selecting detergents or disinfectants to use in washer disinfectors, there is another balance to be found between material compatibility, efficacy and staff safety. There have been reports of visible contamination on instruments after cleaning, when it was mandated that a neutral detergent had to be used. Input from an AED is essential when selecting the most appropriate cleaning products
An additional challenge will be the focus on non-COVID related pathogens, which are emerging with the potential to cause healthcare associated infections. For almost two years, SARS-CoV-2 has been the main pathogen of concern, but bacteria like Burkholderia (B.) cepacian are easily transmitted, difficult to detect, able to survive in harsh conditions and may cause lethal infections in susceptible patients. They remain – for now – very much under the radar
The NHS drive for sustainability will prove to be key in 2022 and beyond, when decontamination choices are being made. To become the world’s first carbon net zero national health system by 2040 will require big changes for the NHS and for NHS Supply Chain. Reducing the use of single-use plastics and using reusable instruments means that there will be increased demands on reprocessing.
Also, the use of robotic surgery looks set to increase as the benefits include increased operative precision and less time in hospital. This means that highly effective decontamination products will be needed for cleaning this sensitive, high value equipment, which will not damage the instruments over time.
Reliability of supply is likely to be another key theme in 2022, with Trusts needing suppliers who not only deliver decontamination products to the highest standards but are also able to ensure constant and reliable supplies. There are a number of key priorities for suppliers of decontamination solutions in 2022. It is essential for suppliers to have considerable experience of the complex needs of hospital infection prevention and control teams; and to work in partnership with these teams to deliver the solutions they are looking for. Decontamination product ranges need to be highly effective, be material compatible and be trusted to deliver on performance and safety.
This should be underpinned by the provision of high quality, regularly updated and where appropriate accredited education for both the purchasers and the end users of the products. It is no longer acceptable for suppliers to simply manufacture and supply products, without a genuine understanding of the market and NHS needs
In addition, with the NHS drive towards sustainability, there will be an increased focus on the value of manufacturers being ISO 9000 accredited. ISO 9000 is a set of standards that helps organisations ensure they meet customer and other stakeholder needs within statutory and regulatory requirements related to a product or service.”
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?’
Ultrasound probes: tackling the risks
Bryn Tudor-Owen, from Nanosonics UK, says that hospitals must tackle the challenges associated with ultrasound probe decontamination in 2022:
“Ultrasound scanning has expanded to almost every healthcare department, its utility particularly spotlighted during the pandemic. Managing documented infection risk associated with the use of these devices is important to support patient safety. Ultrasound probes will often contact mucous membranes, non-intact skin (semi-critical devices), sterile tissue and/or the bloodstream (critical devices). These devices require a minimum of validated reprocessing that is bactericidal, virucidal, fungicidal and mycobactericidal (termed ‘high level disinfection’ internationally), and the use of a sterile sheath.
One of the key challenges for decontamination in 2022 will be to locate which hospital departments are using ultrasound. Following this, to profile how ultrasound probes are being used and in which procedures, and which patient tissues they are expected to contact for each procedure. It’s important to identify and close potential infection prevention gaps, to ensure these devices are properly prepared for every patient according to ultrasound infection prevention guidelines from the United Kingdom.
Semi-critical and critical ultrasound probes are routinely reprocessed at the patient point of care. A priority should be adoption of new, automated technologies for these devices, that integrate with the clinical workflow. Automated disinfection methods are standardised and validated, and therefore considered best practice across Europe for semi-critical ultrasound probes. The Robert Koch Institute reaffirmed this, in November 2021, stating that manual wipe disinfection is prone to human factors and there is no known way to validate wipe disinfection on site. Automated devices additionally offer digitised traceability supporting standardisation and quality care. Facilities should ensure selected decontamination processes are compatible with ultrasound probes used in each department to avoid probe damage and voided warranties.”
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.
Medical device design: key challenges
Medical device design is a key issue that needs to be addressed in 2022, according to Jimmy Walker. Manufacturers are still designing instruments without sufficient consideration as to how they can be cleaned and decontaminated. Some hospitals have taken control and refused to use these instruments, putting pressure on the manufacturers to address these infection risk challenges, he revealed.
We can talk about technology and the exciting innovation of the future, but sometimes you have to get the basics right.” he commented. “Even manual instruments are being placed on the market that cannot be properly cleaned. There is a lot of work to be done to address these issues.”
Conclusion
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.
Sustainability: how can the sector help?
In 2022, CSC will be holding its 60th Anniversary Annual Scientific Meeting at the Crowne Plaza, Stratford-upon-Avon, 4-5 April 2022. This year, the event will also be live streamed. Later in the year, the Autumn 2022 Study Day will provide further opportunities for education and networking. There will be a strong sustainability focus, with input from partnering organisations – including Royal College of Nursing (RCN) and BSG. In October 2020, the NHS became the world’s first health service to commit to reaching carbon net zero, in response to the profound and growing threat to health posed by climate change.
Sustainability will become a key focus area for decontamination units – whether it is discussion on minimising the environmental impact of detergents and chemistries, improving energy efficiency/ water consumption during decontamination processes, reducing packaging waste, singleuse instrumentation vs reusable alternatives, or investigating the potential of reprocessing personal protective equipment (PPE).
According to a study published in the Journal of the Royal Society of Medicine, 1 the carbon footprint of personal protective equipment (PPE) provided to health and social care staff in England, during the first six months of the COVID-19 pandemic, was equivalent to flying from London to New York 244 times every day.1 Decontamination units could have a significant role to play by investigating the potential to safely decontaminate reusable PPE.
“NHS Improvement, AfPP and RCN are all looking at the efficiencies that can be achieved, in relation to PPE usage. Instead of throwing away large volumes of clinical waste, the NHS could be supported to reduce its environmental impact. Decontamination departments also need to look at energy savings and other aspects that can contribute to reducing the environmental impact of the NHS – this will be an important trend and CSC will be developing a training day on ‘green decontamination and sustainability’ to help find ways to drive this agenda forward,” Jimmy Walker concluded.
For information on the CSC, visit: https://centralsterilisingclub.org
References
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
