Moist heat of 38 °C is not conducive to concentration; and neither did the surroundings of the Sunway Lagoon Hotel in Petaling Jaya, Malaysia, with its azure blue swimming pool exactly inspire one to get down to work. But appearances are deceptive: the delegates attending the first IFSS congress were able at most to gaze longingly at the swimming pool from the windows of the 15th story, because the conference had made provision for such a cornucopia of information and lectures that the numerous diversions were soon forgotten.
The official opening of the congress was preceded on Sunday by a workshop organised by ASP Johnson & Johnson. Various speakers reported on the current state of matters relating to nosocomial infections (NCIs) and infection prevention worldwide. Victor Lim from the National University of Malaysia emphasised for example that patients are meantime going into hospital with the expectation of coming out again alive and summarised how conditions have changed in Malaysia on the basis of a quality assurance programme established in the mid eighties. Especially the employment of infection control nurses, of whom there is meantime at least one in every government hospital, has resulted for example in a marked reduction in postoperative wound infections and also in the incidence of patients infected or colonised by MRSA.
Martin Favero, Johnson & Johnson, dealt with the issue of the influence that NCIs and certain "new" or re-emerging pathogens have on sterilisation strategies. Especially prions are addressing hitherto unknown demands to reprocessing. In this context Favero pointed out that fear and politics appear to have often supplanted scientific approaches when it comes to formulating guidelines.
Other lectures focused on the influence that ISO 14937 has on sterilisation practices worldwide, on parametric release, validation of plasma sterilisation processes, cleaning and reprocessing of endoscopes as well as on reprocessing of single-use instruments. In her talk, Gillian Sills outlined working conditions in the sterilisation department and portrayed a vision of the ideal work setting.
This wide-ranging event was a good preparation for the lectures given during the IFSS congress in the days to come. Gillian Sills opened the programme on Monday morning with a roll call of the participating countries - an impressive presentation because after all 41 countries were being represented by the more than 550 delegates. The Malaysian Minister of Health Chua Jui Meng was impressed, too. In his opening speech he elaborated on the fact that especially in Malaysia the importance of infection prevention and in this context also of sterile supply has been gaining increasing recognition in the past few years. The sterilisation departments have been accordingly upgraded and modernised or are in the process of doing so. In an excursion that touched upon various countries and epochs he stressed that infection prevention has played a role at all times, and is possibly more important today than ever before because in medicine we are often dealing with more invasive measures and at the same time - as a result of weakened immune systems - with "more susceptible" patients.
Hygiene deficits - a problem worldwide
David Hurrell, UK, reported at the beginning on an official investigation into sterile supply in Scotland during which considerable shortcomings with potentially adverse implications for the health of personnel and patients came to light. He elaborated on various key issues that must be taken account of for sterile supply, e.g. the organisational form (local versus central processing, with local processing being justified only in isolated cases) adequate cleaning, validation or how to deal with single-use instruments whose reprocessing is already prohibited in the United Kingdom. Today CJD and some other re-emerging diseases and pathogens are posing special challenges to sterile supply, which can be met especially with "well" personnel, refering to the fact that staff have to be well-trained, well-equipped, but also well-recognised within the hospital system.
The afternoon of the first conference day was devoted to various workshops on, inter alia, ultrasonic cleaning and tracking systems.
Shaheen Mehtar, South Africa, opened the second day of the conference with a talk on infection prevention and showed on the basis of impressive photographs that nosocomial infections and hygiene deficits are a problem worldwide. But in recent times it has been possible to counter the belief, apparently still widespread in many places, that one goes into hospital to die, and Mehtar insisted that here only one's own health can serve as a yardstick; hence the question must be phrased as follows: "Would I myself undergo treatment here?"
Adriano Duse, South Africa, similarly described major hygiene shortcomings, with a lack of clean water often constituting a basic problem. Organisational drawbacks that result in responsibilities and accountabilities not being clarified further aggravate existing problems. The key to success, i.e. to an improvement in hygiene conditions - as would emerge from both lectures - is not to be found in greater investments or better equipment but above all in personnel training. Even if training measures cost money, ultimately a vast amount of money can be saved through effective infection prophylaxis.
Paula Brenner Friedmann, Chile, described conditions in her country. An investigation conducted in 1982 into the state of sterile supply revealed serious shortcomings here. An outbreak of S. marcescens due to contaminated disinfectant solutions resulted in 1983 ultimately in the establishment of a government programme for infection control, comprising regular obligatory checks and training programmes. It has thus been possible to ensure compliance with the regulations in more than 60% of cases; Friedmann stated that surveillance as well as the regulations relating to exposure of personnel to toxic substances still needs to be improved.
Masato Kamitami described conditions in Japan where rising costs have likewise made restructuring of the healthcare sector necessary. He too focused attention on the safety of personnel, e.g. as regards ETO sterilisation, and described this as an essential component of a quality assurance system.
Wayne Spencer, UK, described the ongoing investigation of decontamination practices in the United Kingdom. So far, the current practices have not been systematically reviewed in all departments. By means of a specially developed procedure called the process assessment tool (PAT), it is hoped to get a detailed picture in order to be able to identify and eliminate areas of risk. With a few citations from the fifties, Spencer emphasised that certain problems and areas of risk have even today by no means become less topical.
Organisation and personnel
Patricia Ching, Hong Kong, highlighted the organisational links between hospital hygiene and the CSSD and stated that cooperation is a valuable win-win partnership. But a precondition here is close cooperation between the staff on the wards and those in the CSSD.
Sylvia Morris, Australia, focused on the interpersonal relationships in a sterile supply department and showed how a novel behavioural model can improve efficiency for personnel. This promotes certain behavioural modes, discouraging others, thus overall creating a positive atmosphere in the department and making it easier to deal with staff members who do not fit into the team. Thanks to the improved communication, the department can concentrate on tangible goals instead of becoming embroiled in interpersonal conflicts. By different means, Morris stated, this can also serve to ultimately cut down considerably on costs.
Suzanne Zayas-Buil, Australia, in her talk on Wednesday also dealt with the subject of personnel and emphasised that the aim of providing the best service possible can only be achieved if staff members are accordingly trained and motivated. She outlined possibilities of how staff can better grasp the necessity of maintaining standards and showed how important special knowledge in this domain is for the efficiency of the department.
Free lectures on the afternoon of the second day of the conference dealt, inter alia, with the subject of CSSD organisation, e.g. the deployment of tracking systems or event-related storage time.
Cleaning - the most important precondition for sterilisation
John Crispin, UK, opened Wednesday's programme with a lecture on the specification and validation of cleaning processes in washer-disinfectors.
Michelle Alfa, Canada, also focused on cleaning, presenting the results of investigations dealing with the processing of narrow lumened instruments. She stated that it was especially important that only accessible surfaces and channels can be adequately cleaned; hence a precise inventory must be taken of the prevailing circumstances in order to establish whether reprocessing is at all possible. Citing cannulatomes as an example of her investigations, she stated that if these prerequisites are not met, the selected reprocessing methods do not suffice in many cases.
Adrie de Bruijn, the Netherlands, described methods for checking cleaning results and showed that the simple and inexpensive ninhydrin test is suitable in many cases for detection of protein residues. But it must be borne in mind that various influence factors can falsify or make it difficult to read the results, thus making it necessary to evaluate these influence factors (e.g. type of swab used, humidity, etc.) in the different departments.
Masaki Takashina, Japan, reported on the use of bioluminescence methods for checking cleaning results. With this method, ATP - which is present in large quantities in human blood - serves as a marker of residual contamination. The examinations have shown that the method is very well suited to measurement of ATP concentration on instruments, thus permitting a clear picture of the residual contamination burden.
Winfried Michels, Germany, presented examinations on cleaning efficiency in washer-disinfectors. Microporous borosilicate filters were contaminated with blood and washed under different constant conditions with various cleaning agents. The success of outcome was verified with the modified OPA method. Alkaline detergents proved to be superior in these investigations and obtained better cleaning results in demineralised water. Enzymes had little, or no, impact on the cleaning result. Furthermore, it was demonstrated that protein denaturation leading to fixation sets in only at 55 °C.
Klaus Roth, Germany, described the demands being addressed to instruments during the various steps of the processing cycle - in the last analysis, it is not only the surgical functions that have to be borne in mind during development but also dismantling, amenability to cleaning, packing, etc. Roth presented the radionuclide method with whose help contaminants can be detected at locations that are difficult to access without destroying the instrument. In combination with other test methods the instrument design can be thus optimised. Using an example, Roth also showed how a special instrument tray for minimally invasive surgical (MIS) instruments has been developed, permitting the well-defined arrangement of all instruments and enabling it to be placed without any further handling with the contaminated instruments in the washer-disinfector. Accordingly, the water flow - which is decisive for the cleaning result - can be optimised. The first test results were very promising, not least in respect of the time saved during processing, which is an important factor for special instruments that are often the only ones of their kind available.
Loan instruments - an alternative?
The lecture given by Susan Ison, Australia, dealt with loan instruments. Loan instrument sets have become a necessity due to the rapid developments for example in orthopedic surgery, since it is impossible to make provision for the large number of special sets required. Based on a special investigation project carried out with loan sets in New South Wales, Australia, she described especially the demands being addressed to the CSSD handling the loan sets. Problems can arise for example if sets are leased to different clients and possibly are not returned in a fully functional state. Also personnel must master all over again the processing of special, in some cases, possibly unfamiliar instruments.
Anthony Leavor, UK, explained from the perspective of a manufacturing company that deals with loan sets how to solve the outlined problems.
Free lectures in the afternoon rounded off the programme. Among other contributions, Henk Winckels, the Netherlands, in his lecture "A Guide to Guidance" provided information on how to deal properly with standards and guidelines.
Thomas Fengler, Germany, presented the results of the "Multicentre study of residual contamination" (see also Central Service 1/2001). Having recorded the actual state for six different instruments during the first phase of the study, further studies are to be now conducted on individual types of instruments.
Day 4: cleaning, tracking, monitoring...
Nandini Shetty, UK, opened the last day of the congress with a report on investigations of the activity of the disinfectant Sterilox. The excellent antimicrobial activity as well as the low toxicity makes this an alternative to glutaraldehyde for processing endoscopes. Shetty pointed out how important adequate cleaning is: efficacy decreases greatly in the presence of protein residues; even after 15 min it was not possible to achieve an adequate disinfectant effect on using contaminated instruments during her investigations.
Jennifer Grainger, Australia, outlined her experience with the introduction of a tracking system. Here the personnel constitute an important factor. For example the full working time of three persons was needed for two months in order to complete numeration and input of all instruments and trays into the computer system. During this phase, which meant extra work, it is very important that the staff members understand the benefits to be gained from the system in the long term, for example being able to dispense finally with repetitive routine writing tasks once the system has been set up. Grainger made it clear that gradual implementation calls for a relatively long period of time. To date, tracking of entire trays has been implemented; traceability of individual instruments must be completed in a further phase.
Hans Wolf, Germany, presented a system for validation of foil sealers and emphasised that while the manufacturer should conduct validation of the sealing process, the user is often left with visual inspection as the only means of checking a seal. By means of the seal-check system, simple archiving is also possible in accordance with legal provisions.
Phil Schneider, USA, presented research findings with the Electronic Test System (ETS), permitting monitoring of all critical parameters of the sterilisation cycle. The instrument records pressure, temperature and time and is able to check the quality of air removal; hence it is easy to perform and read the daily steam penetration test as well as archive the result. Due to the numerous measurement parameters, the instrument also makes provision for selective troubleshooting; borderline results can be detected on time.
Small steam sterilisers
Joost van Doornmalen, the Netherlands, described the special problems that can arise when validating and checking small steam sterilisers. Furthermore, van Doornmalen showed on the basis of a measurement series conducted with different sterilisers that the different requirements addressed to performance and safety cannot be completely met by any of the small steam sterilisers examined. Hence this makes it all the more important to ensure that the steriliser and the selected sterilisation process are definitely matched to the instruments for which they are intended.
Sterilisation and communication
The "crowning finale" on the last day was the lecture by Jack van Asten, the Netherlands, who focused on the numerous possible meanings of the letters "I.T". In addition to "information technology", the astonished audience learned that this abbreviation could also denote e.g. "innovative technology" or "information transfer". Van Asten ascribed tremendous importance to the latter and stressed that contrary to the widespread belief one does not need a computer for this. The direct information transfer between persons is still the basis for "interactive thinking" - a further meaning of I.T. - irrespective of whether it takes place verbally, electronically, or is even scribbled on a beer mat. And successful information transfer is ultimately the basis for successful working together - not only in the field of sterilisation.
This final comment was representative at the same time of both the goal and the successful outcome of the congress, because each participant was surely able to take home valuable information, which can be useful during the daily work and - almost more important - make new contacts which hold out prospects in the future for fruitful and valuable "IT" (information transfer).
Room for improvement
As a final remark it should be noted that there is surely no "first congress" whose organisation cannot be improved. Even if the surroundings of the chosen conference venue were very attractive, it must not be forgotten that the accommodation rates in a five-star hotel as well as the congress fee of 350 pounds made it impossible for many people to attend, and unfortunately especially for "normal" staff members in sterilisation departments. This was also the case for delegates "from the neighbourhood", as highlighted by the fact that for example of the more than 250 delegates from Malaysia, only six had themselves borne the costs for attending the congress. With all due respect to the commitment shown by industry, it would surely have been easy - especially in Malaysia - by resorting to a few simple measures to enable the participation of potential delegates who would have to pay for themselves - even if this meant only providing a broader range of (less expensive) alternatives for accommodation, as for example given in the registration form for the scheduled EFHSS congress in November.
Because it would surely be in the interest of all concerned to make this important information transfer available on a broader basis, and this basis, as clearly shown on every day of the congress, is the people who work in the sterilisation departments all over the world.
Dr. Gudrun Droop