Cleaning with surgical precision

25 November 2006 10:20

With hundreds of patients operated on every day at Norfolk's biggest hospital, one of the key behind-the-scenes challenges is keeping a steady flow of sterilised instruments for surgeons to use.

It is a task that is largely unseen, taking place in the depths of the Norfolk and Norwich University Hospital by a specialist team working round-the-clock, seven days a week.

Each instrument, from the most common pair of scissors to highly specialised one-off tools, need to be collected from the operating theatre, washed, inspected, re-packed and then sterilised to the highest standards, ready in time for the next round of procedures.

In a typical 24-hour period, the Sterile Services Department (SSD) at the N&N will clean up to 29,000 surgical instruments. Situated directly below most of the 28 operating theatres at the £229m PFI hospital at Colney, a team of 80 people cleanse the instruments in a process that is as much labour-intensive as it is hi-tech.

SSD manager David Scotton explained: "Our main customer is the operating theatres but we also serve the day procedure unit, wards, GPs and health centres.

"We get a lot of the work in the early evenings when the afternoon operating lists have finished and we need to work hard to get the instruments back in circulation for the next day.

"There is a degree of skill required - it takes six months to fully train a sterile services technician, and they need to be able to recognise and deal appropriately with specialist instruments."

Once the surgeon has completed the operation, all the dirty instruments are brought down to the decontam-ination areas in sealed trolleys. Many of the instruments are kept together in specialist sets but all are tracked through the cleansing process with a bar-coding system that is logged throughout by a computer programme.

"This means we can trace an instrument set through the sterilisation process and we can demonstrate that those instruments are sterile," said Mr Scotton.

"But more than that, we can trace instruments to a particular operating theatre and a particular patient which is important if there is a problem with a patient."

The department operates six wash-disinfectors and seven steam sterilisers, supported by advanced tracking and monitoring software to ensure instruments are tracked all the way through the sterilisation process and back to the operating theatres

A typical set of instruments can include blade handles, dissecting forceps, needle holders, suckers and scissors.

But Mr Scotton added: "Some are for specialist procedures, particul-arly in orthopaedics for knee or hip replacements and for some instru-ments, there is only one set in existence in the trust."

These can be such devices as a type of stapedectomy instrument for operations of the inner ear, whereas there may be 50 sets of major surgery instruments.

Most instrument sets are turned around for re-use in 12 hours, though this can be as little as three hours.

The SSD is in a windowless, highly controlled environment, to retain the purity of the air and avoid any external contamination. Particle tests are regularly carried out to ensure the environment is clean.

SSD team leader Jilly Gardner explained that after the used instruments come down from the operating theatres in the lift, they are scanned into the system for traceability, emptied out of trays, opened up and checked and then washed, brushed or flushed out.

Items in need of repair or replacement are identified. Any sharp blades are removed in the operating theatre and disposed of separately.

"There are literally thousands of instruments but the technicians know them all by name," said Mrs Gardner.

A robotic system automatically loads the trays into the £35,000 state-of-the-art washers, where the items are also disinfected to a temperature of 91C for just under an hour. They are then extracted from the washers into the sterile area of the SSD.

Each item is hand checked and placed into trays.

Technician Harriet Guy said: "Every instrument that comes through has to be checked to make sure they are working correctly for the surgeon and then laid out in a specific order for use in theatre before going on to the next stage to be sterilised."

Bowls, swabs and other items are added before each packed tray is methodically wrapped in special paper in a way that allows the sterilising steam to get into each nook and cranny of the instruments to clean them to a standard ready for re-use in the next operation.

From there, the instruments go into a steam sterilisation unit for 48 minutes to be cleansed in a vacuum up to a temperature of 137C before being stored ready to be returned to the theatres when needed.

Within the department, there is a high level of commitment to standards of cleanliness.

But Mrs Gardner added: "The job is also very enjoyable and satisfying because at the end of the day we are helping make these instruments available again to help people get treatment. We know it could be any of our family members just as much as anyone else.

In a typical day, the N&N sees 187 day patients, 219 emergency patients, 74 routine patients, 1,459 outpatients and 220 A&E patients, many of whom will require surgical instruments processed through the SSD.

The SSD has recently been awarded top European certification for its high quality standards. The decontamination and sterilisation equipment is tested, maintained and validated to the highest national and international standards. The department is now fully accredited to ISO 9001:2000; ISO 13485:2003 and the Medical Device Directive 93/42/EEC.

Mr Scotton said: "This type of accreditation is difficult to achieve and the staff have worked extremely hard towards these standards."

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