Healthcare Associated Infections (HAI)
This article delves into the topic of Healthcare Associated Infections (HAI or HCAI), defined as “infections which occur in a patient during the process of care in a hospital or any other healthcare facility which was not present or incubating at the time of admission”.
Even in the most developed healthcare systems, in countries such as America on any given day, about one in 31 hospital patients has at least one healthcare-associated infection. (1)
Hospitals of course, filled with sick patients, need to implement several layers of precautions to ensure that the spread of infections is contained. These precautions are known as Infection Prevention and Control (IPC) programmes and they restrict HAIs as well as prevent antimicrobial resistance (AMR) through the excess distribution of antibiotics.
Unfortunately, this is not the case in Sri Lanka, as the number of HAI/HCAI cases is extremely high and the common solution practiced is the administration of large doses of antibiotics. This leads to the increase in pathogen (bacteria/ virus) resistance, lengthening the hospital stay of the patients in most cases.
IPC programmes provide strict guidelines and controls to manage any spread of HAI. Starting with specialized medical teams trained in combating HAIs, a continuous surveillance system to track any outbreaks, and the creation and maintaining of sterile operating environments. It is under this layer of precautions that a Central Sterile Supply Department (CSSD) has become a key part of IPCs in modern Hospitals.
Sterilization of Instruments is a vital to prevent infections (P2)
What is a CSSD?
A CSSD is a designated area where the sterilization of instruments takes place in a hospital prior to any surgery or procedure. A proper CSSD with a well-educated staff can result in a reduction of the spread of infection in a hospital. The below list of equipment is commonly found in CSSDs:
Steam Sterilizers – A common piece of equipment in any CSSD, the Steam Sterilizer sterilizes the instruments placed inside it by exposing them to high temperature and pressurized steam between 121˚C -134˚C, killing any microorganisms or spores. The Steam Sterilizer is suitable for most heat resistant instruments.
Washer Disinfectors – First, the instruments are washed using hot and cold water to remove any solid residue from its surface, then doused with chemical detergents, usually with an acid or alkaline, followed by a neutralizer. It is then rinsed to remove the chemicals, disinfected using high temperature of 93˚C and finally dried.
Washer Disinfectors are used instead of a manual washing process to improve efficiency and ensure proper cleaning and disinfection takes place. Also manual cleaning processes instead of Washer Disinfector machines can cause harm to the staff cleaning these instruments due to the use of chemicals, and cause irritation when it makes contact with the skin or eyes.
Washer Disinfectors are not widely or properly used in Sri Lanka due to a lack of funds and knowledge about them. Instead, hospitals manually wash their instruments in makeshift spaces not up to the above guidelines, using available staff as required.
Low Temperature Sterilizers – These are used where the instruments to be decontaminated are heat sensitive and can get damaged by high temperature pressurized steam.
There are 3 methods currently in the international market for Low Temperature Sterilization, the latest and most advanced being the Low Temperature Plasma Sterilizer that uses a vaporized 59% Hydrogen Peroxide solution and sterilizing temperature of 50˚C - 55˚C to conduct the process of sterilization.
Ultrasonic cleaners – By employing the principle of ultrasound reverse suction, dirt is removed from the inside of cannulated instruments (tubes) efficiently in a relatively short time, cleaning them to standard and ensuring the reliability of subsequent decontamination processes.
Depending on the type of instrument and the material it is made, there are standards to sterilizing it (P3)
Current situation in Sri Lanka
In order to obtain necessary international certifications, all private Hospitals in Sri Lanka have implemented proper CSSD systems.
However, in the Government sector most hospitals have single door Steam Sterilizer areas without proper decontamination, sterilization or cleaning guidelines which, over time, results in damage to the surgical instruments. And, there are no parameters for monitoring these machines or to check the sterility of the devices. (There are parameters however, it is not practiced in Sri Lankan Hospitals)
The primary hurdles barring the implementation of these more advanced methods of sterilization and the adoption of world class CSSD standards are cost and training. Even if funding were secured to purchase these machines, the staff must be properly educated in its operation, monitoring and maintenance, if the machines are to function for any length of time.
Hospitals need to implement best practices to reduce costs in the long run (P4)
Progress is a slow process as most hospitals do not upgrade their equipment, methods or best practices unless they absolutely must, and almost never in an attempt to pioneer the use of new technology.
Sri Lanka has a long way to go before it is considered a country with cutting edge medical care, and the only real way to push for upgrades is by patients and customers demanding better equipment as a basic requirement from their health service providers.