Introduction
The provision of safe medical services suggests that the environment used for treatment is hygienic. Given that people visit hospitals to receive treatment for various illnesses it is clear that decontaminating these environments goes hand in hand with the quality of service offered. It has been observed in operating theatres that surgical site infections pose a significant problem in modern medicine. Such infections may be identified as deep infections or superficial infections. Deep infections are especially complicated and could lead to re-operation or even life-threatening situations (Dharan & Pittet 2002, p. 79).
These kinds of infections are caused by a variety of factors such as surgeon’s skill, type of operation, insertion of implants and foreign material, degree of surgical preparation, immune state of the patient and contamination of the inanimate environment. Reduction of such infections can only be achieved by increasing the bacterial management within the operating theatre and the hospital (Dharan & Pittet 2002, p. 79). It is thus very important to monitor the environment and provide some degree of control on the sterility of the environment within medical facilities.
Further, it has been observed that infection with resistant strains of bacteria in hospitals has become common around the world. Harmful microorganisms such as Staphylococcus aureus (MRSA) with increased resistance to drugs have been reported to be increasing within medical facilities. This case is especially alarming because this microorganism is among the leading causes of surgical site infection that have been identified (French, Otter, Shannon, Adams, Watling & Parks 2004, p. 32). Its control within the hospital setting is therefore crucial in ensuring patients undergoing operations do not succumb to unnecessary infections. In this report, the discussion will revolve around subjects of concern with regards to decontamination of medical equipment and the environment to improve quality of service.
Regulations for Sterile Services Departments
In recent years providers of primary care have begun to play an increasingly dominant role in health services covering services previously considered the domain of large acute hospitals. This situation has led to rigorous and intense decontamination practices in both large and small hospitals. Regulations currently require all care centers to consider decontamination options available and make informed choices on which techniques to implement. The Department of Health in the UK has gone a step further and published various materials that seek to provide information on guidance and decontamination policy (Rayfield 2007, p. 2).
Current standards dictate that decontamination is carried out within a centralized sterile service department. However, in cases where local decontamination is the only option available such as in dentistry the procedure must undergo validation to meet departmental requirements (Rayfield 2007, p. 3). Currently, standards require the following actions to be performed within a sterile services department. The disposal of all singe use medical equipment; decontamination within the department equipped with appropriate facilities and trained staff; decontamination of endoscopes according to national requirements; manual cleaning is restricted to devices incompatible with automated cleaning; audit trail for recycled items; policies in place to ensure staff is properly attired and appropriate staff training (Rayfield 2007, p. 6).
Cleanroom Regulations
The production of medical pharmaceutical materials through procedures such as the mixing of compounds is required by regulation to be undertaken within a sterile environment. These guidelines are included in the European Commission Guide to good manufacturing practices as well as the US Pharmacopoeia (Caselli-Fernandez & Terkola 2006, p. 29). These regulations require the cleanroom facility, equipment and staff to comply with very strict regulations on levels of disinfection to be maintained. To successfully perform this constant monitoring needs to be performed by personnel who are able to take remedial action when cleanliness levels are out of bounds.
General requirements state that all surfaces must be smooth, covered and impervious to prevent the accumulation of dust particles. A high degree of resistance is also crucial to allow for continuous sanitization with required agents. Only required furniture is allowed in the cleanroom. Plumbing should be done to prevent inaccessible areas and pendant ceilings should be sealed. An anteroom should be included in the design to act as an airlock between the room and the external environment (Caselli-Fernandez & Terkola 2006, p. 30). This room has two doors that are never to be opened simultaneously. In addition to this, there should be mechanisms that monitor temperature, humidity and pressure both in and outside the cleanroom.
The room should be equipped with an air filter operating at least 0.45ms which should always be on 30 minutes before entering into the room (Caselli-Fernandez & Terkola 2006, p. 30). The anteroom should be used for the sanitization of people and items before entering the room. The anteroom should have markings indicating a maximum number of items e.g. stacked cartons allowed. The cleanroom should be maintained within the required parameters at all times during use and during rest any breach requiring appropriate remedial action (Caselli-Fernandez & Terkola 2006, p. 31).
Decontamination of the Hospital Room/Ward to Eradicate Staphylococcus aureus
The hospital environment has been known to harbor the staphylococcus aureus bacteria. This microorganism has been known to cause MRSA infection though it is has been observed that it may not be the primary source of the infection (French et al. 2004, p. 33). It has been observed that the number of blood samples with the microorganism that is resistant to methicillin has risen considerably in hospitals and referral institutions. This position suggests that the hospital environment has been neglected despite its importance in hospital cross-infection (Dawe 2008). Similar trends have been observed in English hospitals where the organism causes the majority of the post-surgical infections. The majority of these MRSA infections are acquired in hospitals and many cases can be prevented with improved decontamination procedures.
Conventional cleaning requires the use of a detergent sanitizer containing 5-15% catatonic surfactant and 5-15% nonionic surfactant diluted in the ratio of 1:500 (French et al. 204, p. 34). The solution is used to clean beds, floors, curtains and damp mop the floor. A more recent approach involves the use of gaseous hydrogen peroxide evenly distributed through the room. The decontamination process using hydrogen peroxide has been found to be over 90% more effective at eradication of MRSA within the hospital environment (French et al. 2004, p. 36). The only disadvantage with this procedure is the amount of time it takes though it is expected that optimization will reduce the time taken to complete the exercise.
Decontamination of Operating Theatres
As earlier mentioned, surgical site infection continues to be a major problem in hospitals today. The risk that such infections pose to patients makes it crucial for the operating environment to be kept free from bio-contamination. To successfully perform this it is essential to keep in mind the source and transport of causative organisms. In most operating theatres over half of the clean site surgical infections are attributable to the normal skin flora of either the patients or staff (Dharan & Pittet 2002, p. 79). Studies indicate that orthopedic surgery often results in lower rates of surgical site infection when the air is purified. Thus we can assume that a higher bacterial count in the air within the operating room increases the risk to the patient.
With regards to the ventilation in the theatre, most modern facilities are equipped with plenum filters that are capable of removing 85-90% of airborne particles (Dharan & Pittet 2002, p. 80). In orthopedic and other implant surgery room’s laminar filtering devices with the efficiency of over 90% removal of airborne particles are utilized. There are few countries that have established bacterial thresholds though most recommend 20 air changes per hour within the operating room. At this rate, it is expected that the formation of colonies can be limited to 50-150 CFU/m3. The United Kingdom stipulates that an empty operating room maintains 35 CFU/m3 and does not exceed 180 CFU/m3 when in operation (Dharan & Pittet 2002, p. 80).
In an ultra-clean air operating environment, the limit is set at below 10cfu/m3 within 30 cm of the wound when conventional clothing is used. When body exhaust gowns are in use the limit is set at below 1 CFU/m3 as stipulated by the UK department of health (Dharan & Pittet 2002, p. 80). These set standards are not as easy to achieve in practice as the aerial bioburden is affected by other external factors. Though at present there is still a lack of international consensus on standards in the operating rooms this could go a long way in improving medical services. The problem lies in agreeing on the mode of sampling, frequency of sampling and tolerable limits of bioburden to be met in operating rooms.
In addition to this the surgical drapes especially the fronts and sleeves of the gowns should be treated with a fluid repellant (Wilson, Loveday, Hoffman & Pratt 2007, p.303). These are considered medical devices by European standards and as such should pose minimal risk to the patient. The surgical staff is also required to wear hoods or masks while in the theatre. Staff education is essential especially with regards to touching the surgical instruments which after sterilization should remain covered with a sterile drape until used (Dharan & Pittet 2002, p. 80).
Steam Sterilization
Sterilization is a process through which microorganisms live on the surface of an item being destroyed. This is essential with regards to hospital items that may be reused on several patients such as surgical equipment. The most widely utilized and dependable method of sterilization involves the use of moist steam under pressure (Rutala 1996, p. 382). This method is popular because it is nontoxic cheap and effective against spores. Due to the rapid distribution of heat and penetrative abilities of steam this method is recommended for all items that are not heat or moisture sensitive such as endoscopes (Isomoto et al. 2006, p. 298). The basic requirement of these systems is the treatment of each item to heat and pressure for a specific amount of time to destroy the organisms.
The ideal steam for sterilization is dry saturated steam issued in the form of a fine mist. The pressure is essential to produce high temperatures needed to eliminate microorganisms. There are two devices mainly used for steam sterilization namely gravity displacement autoclave and the high-speed pre vacuum sterilizer. The two common temperatures measurements for effective sterilization are 121C and 135C. For effective sterilization at 121C hospital items must be maintained in the equipment for 30 minutes in the gravity displacement autoclave equipment. Otherwise for 4 minutes when a temperature of 135C is applied in the pre vacuum sterilizer (Rutala 1996, p.382).
Ethylene Oxide Sterilization
Ethylene oxide is a flammable, colorless and explosive gas used in the sterilization of medical equipment. This technique of sterilization is commonly used when the items can not be steam-sterilized. The gas is mixed with 10-20%carbon dioxide or chlorofluorocarbon (CFC) to reduce explosive and fire hazards. However, the role of CFC in the ozone has seen their use thus the introduction of hydrochlorofluorocarbons as an alternative (Rutala 1996, p. 382). The efficacy of this gas is due to the alkylation of essential proteins in the organism. This chemical procedure (Alkylation) entails the exchange of the hydrogen atom with an atom of the alkyl group resulting in abnormal replication in microbial cells and causing irregular cell metabolism.
Just as with steam sterilization in this process best performance requires four parameters are satisfied namely, the concentration of gas, exposure time, humidity and temperature. The operational range for these parameters requires a concentration of 450-1200 mg/L; a temperature of 29C-65C; humidity of 45-85% and exposure for a duration of 2-5 hours (Rutala 1996, p. 383). In certain cases increased concentration of gas and temperature can reduce the time taken t to sterilize equipment. The organism B subtilis is used for biological indicators of the effectiveness of the procedure.
Dry Heat Sterilizers
The sterilization of microorganisms can also be achieved by using dry heat which oxidizes microorganisms. For substances that are prone to damage by exposure to moisture or impenetrable by heat such as powders or petroleum-based products, this approach is favored. This approach provides the advantage that it penetrates metal objects well and does not corrode sharp instruments. However, the approach also offers the disadvantage that it kills microorganisms slowly. The common time and temperatures used in hot air sterilizers are 60 minutes at 170C, 120 minutes at 160C and 150 minutes at 150C (Rutala 1996, p. 383). The microorganism B subtilis is used to monitor the efficacy of heat sterilization because of the resistance of spores to heat.
Good Practice to aid the Decontamination of Surgical Sites
It is essential to remove unnecessary tables and equipment and rearrange the room to allow easier movement and avoid dust accumulation. If the room is equipped with air filtration devices these should be switched n at least 30 minutes before the operation to allow for required parameters to be met before the operation (Caselli-Fernandez & Terkola 2006, p. 29). In addition to this, it is good practice to perform a visual inspection of the site and sterilization of lights and the floor before the operation. During the operation, leak-proof containers are useful for discarding all material that has been used. If there are any spills of blood or other organic matter these should be mopped with disposable absorbent (Letexier 2007, p. 27).
Any samples should be properly labeled as biohazards and placed in a leak-proof container prior to transporting. The staff is expected to ensure they scrub their hands and arms up to the elbows with water and disinfectant. The staff must wear hair and shoe covers and don knee length that are closed at the wrists and in front. Sterile gloves must be used at all times within the operating site (LeTexier 2007, p. 31).
Risks Associated with Poorly Sterilized Facilities/Equipment
In the 19th century, a common risk that affected surgical patients was the infection-related fever and the subsequent contraction of sepsis. Patients who were infected often succumbed and died due as a result. This trend was only reversed by the introduction of post-operative antiseptic care which if not maintained could lead to increased patient morbidity (LeTexier 2007, p. 26). This risk is still very real without appropriate antiseptic measures on patients after a surgical procedure.
However, in this age, the most common risks include MRSA and Vancomycin-resistant Enterococci or VRE. These microorganisms have developed resistance to some of the components used in hospital decontamination and as such continue to threaten the lives of many patients (LeTexier 2007, p. 26). In addition to these risks, there is also the risk of contracting other diseases such as HIV and the highly contagious seasonal influenza disorders such as H1N1.
Conclusion
In this report, the discussion has presented information to enlighten the reader on decontamination and the associated procedures in the hospital environment. It has been established that the medical profession has been gradually making measures to ensure patients are safe within the medical facilities. The main risk to patients arises from contracting diseases while visiting these facilities. Since the facilities are a crucial component for the entire society it is necessary to improve decontamination standards within them to safeguard patients.
In the paper, several methods were discussed and their efficacy was considered for decontamination. However, their successful implementation has been successful in some regions and less successful in others. There appears to be a need to resolve the regulations for operating within the medical profession. This case is made even more urgent by the rise of drug-resistant microbes within the hospitals.
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