The battle against healthcare-associated infections (HCAIs) continues and national targets, backed by legislation and codes of practice, have ensured that infection prevention and control (IPC) remains a top priority for NHS Trusts. The NHS as a whole has made significant inroads in this area over recent years, achieving more than a 60% reduction in MRSA bacteraemias alone for the first three quarters of 2008/09, but the battle is far from over. The importance of the issue has forced healthcare professionals and industries to step back and take a fresh look at all aspects of IPC, from basic cleanliness and sterile services, to better mechanisms for prevention. So how “clean” is clean? Are the cleaning processes currently in place as efficient and effective as they could be? Moreover, just because something is visibly clean, how sure can you be that it is microbiologically clean? What is abundantly clear is that no single technology or agent can work alone to combat infection and keep it under control. An arsenal of antimicrobial weapons is required, combined with a strong emphasis on good hand hygiene, clinical education and recommended practice guidelines, as well as the foresight to recognise the benefits that thorough, proactive prevention can bring.
A higher priority for prevention
Historically, it has been the norm to deal with problems that present themselves rather than taking any kind of preventative measures. But, in recent years, staff, patients and even visitors have been educated about the importance of infection prevention, and it is emerging as a worthy target for long-term investment. Infection prevention focuses on stopping the proliferation of microbiological agents which could cause infection, and covers everything from surface disinfectants and cleaners, through to hand disinfection and wide area total decontamination systems. The need for constant vigilance is potentially a major stumbling block in proactive infection prevention strategies. For example, staff and patients are constantly provided with warnings and educational material regarding hand hygiene – and there are dispensers wherever you look in many clinical settings – but does everyone use them as much as they should? Is the level of attention being paid beginning to flag in the face of the continual bombardment of information? There are also more practical issues which must be addressed to maximise conformity to hygiene guidelines. The formulation of the hand disinfectants, for example, can be a significant factor in compliance, as healthcare workers may stop using them in the correct way if there are long-term detrimental effects on the skin. Most disinfectant hand gels are based on a 70% alcohol formulation, but independent researchers have shown that a 60% to 80% alcohol concentration range is effective, depending on the types of alcohol used in the formulation. Introduction of hand gels with a lower alcohol concentration, but still within the effective range, is a straightforward step which could encourage greater compliance, simply by being kinder to hands.
Insight offers efficiency
Understanding the obstacles to improving clinical hygiene practices is crucial, as methods must be both practical and costeffective for hospitals to implement. This is one area in which the IPC industry has seen constant growth over the last few years, with many suppliers now offering IPC consultancy services. By providing expert advice and independent scrutiny of procedures, these services can help to improve efficiency at minimal expense, using experience gained in other Trusts to develop practicable guidelines, increasing the likelihood of compliance. While, for individual hygiene protocols, the onus must be on training and education to increase the likelihood of success, decontamination of rooms, wards and clinic areas requires a more systematic approach, scrutinising the equipment, procedures and chemistries used to see where improvements can be made. Proactive cleaning and sterilisation policies are already widely accepted as a means of both combating existing outbreaks and preventing the spread of infection, but are the processes truly effective? Cleaners may do a very good job of wiping down surfaces, but are they using the most suitable equipment? Furthermore, are the disinfectant agents provided being given the chance to be fully effective? Most of these chemicals work on the basis of a fixed contact time, for example 15 minutes. However, on a warm day with windows open, the disinfectant may actually have evaporated within just a few minutes, limiting the efficiency of decontamination. Add to this the escalating problem of highly resistant micro-organisms, and there is a strong case for re-examination of even these basic practices, across every clinical discipline.
Staying one step ahead of resistance
Heat, in the form of steam, has long been and still remains the most cost-effective and efficient method for sterilising instruments where practicable, currently representing about 80% of all sterilisation throughout the world. However, the emergence of new surgical techniques and instruments, most notably for the growing field of endoscopy, has brought new cleaning challenges; made of a range of materials with different properties, an endoscope costing anything up to £30,000 would simply rip apart in a steam steriliser. Until recently, aldehyde-based disinfectants have been used instead, but some aldehydes have now been withdrawn due to harmful side effects experienced by users, and the environmental impact of their disposal leaves a lot to be desired. There have been several incidences reported where micro-organisms have developed resistance to aldehydes, and proteins, such as those in prion-based diseases like vCJD, are fixed in a “biofilm” that can build up on instruments over time, rather than being destroyed. Although sterilised, these instruments are not actually clean, and there is concern that prions could remain dormant in the film. To overcome these obstacles, many companies within the IPC sector have now established active research programmes, with the aim of keeping one step ahead of infectious agents, understanding how a resistance mechanism develops before it actually happens. A practical alternative, which is rapidly gaining in popularity, is the use of oxidising agents, such as vaporised hydrogen peroxide (VHP). Oxidising agents are more aggressive than aldehydes in their anti-microbial action but their environmental impact, on both users and disposal, is far safer. Hydrogen peroxide effectively destroys proteins and the cell walls of micro-organisms, and can be controlled using catalysts. In the right formulations and dilutions, it can be applied very safely, and it breaks down into oxygen and water. Micro-organisms do of course naturally develop resistance by continually evolving but, so far, it appears to be more difficult for them to develop resistance to hydrogen peroxide, possibly because of its aggressive action.
Large-scale decontamination
A multitude of oxidising agent-based room decontamination systems and consumables now exist, available from a variety of specialist IPC providers. These vapour-based instruments overcome the restrictions of agents that work on the basis of contact time, and consistently achieve extremely high levels of kill. Some Trusts are already using these systems in a proactive manner, routinely decontaminating areas on a regular basis, and this is having a significantly positive impact on the number of outbreaks occurring. Although, on the face of it, this might sound impractical and expensive – as wards must effectively be shut for hours at a time – this must be weighed against the potential costs and inconvenience of reactive decontaminations at short notice, as well as the adverse effects an outbreak has on patients’ welfare and confidence in the care they receive.
A coming of age for sterile services
Regardless of which aspect of IPC you consider, sterile service departments (SSDs) are at its centre, representing the frontline in the fight against infection. Essentially, anything that is decontaminated and reused in a hospital is tracked through SSDs, and follows a well-defined progression of coming used and “dirty” from one patient, to going pristine and sterile to the next. There is invariably a clear process in place, mapping out every step each item goes through in terms of transportation, cleaning, sterilising, wrapping and placing in a set ready for re-use. It can be anything from bed pans to surgical instruments, to boots worn by the surgical teams, but it is all about killing bugs in a way which is safe for the environment, the operators and the patients, without damaging the equipment itself. Thanks to the increased emphasis on infection prevention, the role of SSDs in control and prevention have undergone a radical transformation in recent years. From an ancillary service, sterile services is now developing a strong scientific basis, and a dedicated education programme has been established to arm staff with invaluable knowledge and awareness of disease. The emergence of sterile services super centres has also changed the whole ethos behind SSDs, and they must now provide a profitable service which can plough money back into their parent Trusts.
One port of call
This overhaul of sterile services’ role has led to a complete re-evaluation of the way SSDs work with the IPC industry. This relationship has traditionally varied significantly across Europe, with SSDs in many EU countries having much closer interaction with suppliers than in the UK. In Spain, for example, SSD managers frequently look for a total solution from a single source, covering everything from initial designs and specifications for the department, to flow of equipment between sterile services and operating theatres, including all details of consumables and logistics. Rather than being simply a hardware provider, the industry partner takes on a consultative role, offering a solution that includes after-sales support, application expertise and training, using its experience and understanding of the process to evaluate the complete workflow, taking into account all the factors that might influence performance, good or bad. There are, in effect, several advantages to single source providers, and this approach is now being more widely adopted in the UK. Working with a single supplier makes sense from a standardisation and regulatory standpoint, using already validated and approved processes and equipment from an experienced partner to reduce costs and simplify approvals. This approach also provides a single point of contact should something go wrong, with clear responsibility for diagnosing and resolving the fault. In addition, SSDs and the hospitals they serve are now frequently CE marked and achieve ISO certification, and it is understandable that they should look for the same reassurance and level of commitment from their suppliers. Successful companies who fit the bill have usually reached independently audited quality control standards, such as ISO certification, kite marks, etc. Their products conform to strict quality and testing requirements, and they invest in fundamental research, analysing different types of infectious diseases to understand how these diseases develop, how they develop resistance and how to tackle this. If you consider large room decontamination systems for example, a number of highly effective instruments and chemistries are now available for this market, with differing capacities and suitable for different sized areas. Which system or chemistry is most appropriate for each Trust is highly dependent on the decontamination strategy it has adopted, and the level of service provision required. It is the level of this service support, in particular, which varies significantly between providers, with some manufacturers only providing either hardware or consumables, while others offer complete packages, tailored to the needs of the individual Trust. Price is of course always an issue, and it is important not to just look at the upfront cost of the capital equipment. But even breaking things down to cost per cycle, including capital, utility, consumables, service support, etc. can be misleading. With more and more financial constraints, validated process solutions are more important than ever, and use of an instrument, protocols and chemistries from a single supplier can simplify this, with complete process validation often possible in a single day. In the capital constrained environment of the NHS, companies now frequently provide financing options and bundled solutions, allowing customers to reduce capital outlay when purchasing equipment in conjunction with consumables and service contracts. Although, at first glance, there may be obvious savings to be made by changing to a different instrument cleaning chemistry, this would mean having to revalidate all the cycles for the new chemistry. It also complicates matters if there is a performance issue in washing – is it due to the washer or the instrument cleaning chemistry? This brings us back to the issue of a single vendor providing the entire solution.
Achieving the right balance
The picture of clinical cleanliness and sterility is changing rapidly but, as with many issues in healthcare, a balance needs to be struck. Fundamental research discovers more each day, and new weapons are continually being added to the HCAI arsenal. However, the potential gains of these innovations need to be weighed against the costs and logistics of implementation, addressing the incumbent risks of environmental pathogens without bringing the health service to a grinding halt through constant change. Greater collaboration between the NHS and industry is a cost effective way of achieving this, allowing IPC companies to develop, validate and fully test new technologies, then using their expertise to guide individual Trusts on the best strategies for implementation.
• Sarah Pilbrow is the senior marketing manager, EMEA Infection Prevention Technologies, Steris.