‘Level 3 BTEC in Decontamination of Reusable Medical Devices: Unit One [2017]’

All the Drivers have to wear the same uniform which consists of black trousers, green tops, yellow high-vis jackets that have ‘Sterile Services’ written on them, an ID badge, some blue disposable gloves and, probably most important, steel toecap shoes. The importance of the uniform: the ID badge is so when they are collecting and delivering the buggies from and to the lorry the staff and public can identify them. The high-vis jackets are vital as the Drivers have to move around the car parks of hospitals and they need to be seen by other Drivers; this is essential in the early mornings and evenings when it is dark. Blue gloves have to be worn because when the Drivers go to pick up the dirty buggies they have to take the sets out of the nearly empty buggies from the theatres and fill up one buggy – as it’s easier to move one buggy than lots – and they help stop contamination from the dirty sets. Finally, the steel toecap boots must be worn at all times for many reasons: for example, when the Drivers decant the buggies to make a full load the sets can drop out when the doors open as sets are very heavy – you don’t want it to land on your feet; also, the buggies have to be pulled round the hospital and if a member of the public or staff walk out in front of you you will need to stop and if the buggy rolls over your feet it will crush your feet without the protection; and lastly, the other main hazard they help with is the tail lift, if it fails when you are loading or unloading the lorry it can crush your feet.

The Drivers also have to watch out for the public in regards to the buggies being touched: if the Driver didn’t wear gloves when decanting buggies and then touched the buggy itself then it would be contaminated – now if a member of the public touched the buggy (for example a child) then they would go round the hospital and be spreading contamination until they washed their hands. The buggies should always be clean before they leave Sterile Services as the staff have to clean the buggies properly with Actichlor before the Drivers can take the buggies back to theatres. Also, the gloves that the Drivers wear when decanting buggies are generally put in the buggy with the dirty sets and discarded in the proper bin bags back at Sterile Services.[^]

The Drivers are responsible for making sure the lorry is in working order: they have to make sure the tyres are not bald; the tail lift works and the lights etc; they also have to make sure the buggies they are going to be moving round the hospital are in working order – for example, the wheels are not rattling and wonky and the door handles are fastened properly; the most important thing is they have to make sure that the buggies in the back of the van are secured with the appropriate straps; and, finally, the Drivers have to fill in the paperwork which consists of the mileage at the beginning and end of the shift, how many clean buggies they delivered to the theatres and how many dirty buggies they picked up and brought back to the Sterile Services Department and any problems have to be recorded for legal reasons.[^]

The potential consequences of not doing the paperwork and making sure everything is in working order regarding the lorry are that: you could break down on the rounds which would cause major disruption to the theatres, especially if the set was of high importance; the more significant problem is if you had an accident in the lorry owing to a problem that should have been checked – for example, if the tail lift came down while you were driving and hit someone’s car or killed someone – one of the first things the police would do is check the paperwork to see if it was the Driver’s fault or not. The buggies have to be checked for similar reasons – if you have a buggy that fails while you are wheeling it round the hospital, the wheels could fail and the buggy could tip over which could hurt the Driver or a member of the public and damage property, but if the buggy is checked properly then it is far less likely to happen.[^]

The bags and containers have to be sealed properly to prevent any spillages and also prevent contamination spreading over the buggy it is being transported in – and also the lorry it is being transported in, as this lorry also has to transport the clean buggies that have been processed and decontaminated. Another reason they have to be labelled correctly is to know where the sets or instruments have come from – this is important in case any sets or spares don’t have any barcodes or etching on them, and another important reason sets have to be labelled correctly is that when a set or spare instrument is wanted for the next day (or on the same day) it will be labelled ‘Fast Track’ which means it will be processed before any of the other sets.[^]

The Drivers bring in the buggies from the Loading Bay and put them in the Wash Room, where they will not be in the way of the staff or emergency exits. The staff in the Wash Room have to go round each buggy with a clip board and write down the time the buggy came in and how many sets are in there. At this point the staff will make sure they have all the PPE on required which consists of a hair net, safety specs or splash visor, a heavy duty apron and your supplied shoes, some sterile blue gloves and some big blue heavy duty gloves and – last but not least – your blue uniform; this is all worn to protect you from splashes to arms, face, body and to stop contamination getting on your clothes and anywhere else in the Department. When the staff are all dressed up they will start by removing the blue OneStep wrap from the sets and place it in the orange disposable bags and the unwrapped sets will go on the little metal tables; when the orange bags are full they have to be tied up and on the side has to be written RCHT SSD, the date, and the ID number of the member of staff who sealed it, then they get carried out to the yellow bins outside ready to be taken to the incinerator. When the buggy is empty and the bags removed then you have to make up some Actichlor – 1 tablet in a bottle made with cold water – you then remove your big blue gloves, get a cloth, get the Actichlor solution and clean the buggy inside and out, then put in the Loading Bay ready for the Drivers.[^]

It is very important to make sure the Wash Room is sealed off from the Packing Room as all the sets that come back from the theatres are contaminated – and you don’t want the contamination to spread to the clean sets that are going to be packed and sent back to the theatres to be used on another patient. There are very strict guidelines in the Wash Room for housekeeping to prevent the spread of contamination to the rest of the Department, for example: at the end of every shift all the surfaces are cleaned down with Actichlor solution; all bins are emptied as soon as they are full and put outside in the big yellow bins; the floors are cleaned and disinfected every day; any blood that has leaked on the floor is cleaned up straight away; the equipment we use to clean the sets is stored in containers provided; and the machines used to clean the floor are never taken out of the Wash Room and are stored in their own area.[^]

In the morning when you come in there are certain things you have to do before you can start: you have to put on your PPE then check everything is clean around the washroom – for example, the washer trolleys that the carriages sit on top of have to be cleaned as they might have blood on from the sets leaking on them; also, the floor must be checked for spills or anything that might be missed so you don’t slip on them; you have to fill up the Actichlor solution bottles; the Supervisor will also check the strainers and filters of the washers before the tanks are filled up in case they are dirty or filled up – failure to do this could result in the sets not being cleaned properly and contamination could be spread into the Clean Room and we also have to fill in the daily checklist to say we have checked the carriages to make sure the nozzles aren’t blocked, the arms are attached properly (if they are blocked they have to be cleaned and unblocked so the water from the washers can spray the sets properly ), the arms have to go round properly if not they could fly off in the machine causing many problems like unclean sets, damage to the washers and carriage damage. Last but not least the cycle numbers for the washers have to checked against HESSDA – the cycle number on HESSDA should be one higher than the Belimed and Neqis independent monitoring system cycle numbers when the machines are empty.[^]

The main problems with not following the housekeeping schedule: if the floor is not clean you could have slips, trips and falls; if the numbers of the HESSDA and the washers aren’t checked and cleaned out properly the sets will have to be non conformed back into the washroom to go round again – this disrupts production and is very problematic if the theatres have asked for an urgent set because the patient is under sedation and they need it as soon as possible (the operation will more than likely have to be cancelled and the patient woken up which will delay treatment); as stated above, the carriages have to be checked or the sets won’t be cleaned properly and may cause damage to the washers if not assembled properly; and the trolleys have to be cleaned to stop contamination spreading round the Wash Room. The main reason for doing the cleaning properly is to stop cross-contamination between the other areas of the Department – you don’t want harmful bacteria to go into the clean room and contaminate the clean sets which will then be used on patients which could infect them.[^]

When the sets are returned the staff have two things they have to watch out for: the first is to check the tray list to see if there are any notes from the Surgeon or Scrub Nurse regarding the instruments or set as a whole; and second thing you have to watch out for is if one or more of the instruments have not been placed back in the set, you have to get a ‘non-conformance’ tag and clip it on the set, inform the Supervisor so they can check it in case they already know about it and then record it on the Q-Pulse program. When this is finished you will get a number to write down on your tray list – this number is so the Managers and Supervisors can track the problem to its conclusion; you then scan it using the Wash Room scanner, both sides if more than one page.[^]

One of the main procedures in SSD is the hand washing which is taken from the World Health Organisation guidelines which has you washing your hands in numerous different positions, then turning the tap off with your elbow and using single-use paper towels to dry your hands; this should take around 15-30 seconds, then you have to do the alcohol rub in the same way as the washing, but the gel dries on its own you don’t have to dry your hands with this. You have to do this when entering the Packing Room and when leaving it, the same goes for the Wash Room and when you go to the toilet. The other legislation we use is COSHH which refers to the chemicals we use for the washers, the tabletop ultrasonic washer, the Actichlor solution and the detergent we use for the sinks that we immerse the instruments in. We also use the Health and Safety Act of 1974 which tells us that we have a duty of care towards ourselves and each other – which basically means that we must make sure that we clean up any obstructions on the floor e.g. bins, trolleys, buggies so there are no slips, trips and falls or major incidents. You also have the manual handling side of things – for example, you have to unload the buggies and place the sets onto metal trollies which are on wheels so you don’t have to carry the big heavy sets round the busy washroom, you can just push the trolley to your sink. You do also have to watch how you pick things up in the washroom because the sets can be heavy – you have to bend your knees and keep your back straight; the same applies to the carriages – it’s best to get help to lift these as you can hurt your back if not lifted properly.[^]

You have to remove your PPE when you go to the toilet and when your shift ends. You do this by first removing your heavy duty blue gloves – as these will be contaminated – next you remove your apron as this will more than likely have blood, chemicals or fat on it from the sets, next is the eye protection, then the hair net and last is the blue nitrile gloves – then you go and wash your hands.[^]

The system we use in Sterile Services to monitor everything is the HESSDA system. How this works is when you have filled up a washer carriage with sets you have to first scan all the sets you have personally checked into the ‘Inspection’ mode; when this has been done you then scan all those sets onto the washer carriage, then load it onto the washer – you have to scan that carriage onto the HESSDA system; when it goes though the wash it then has to be checked on the system to make sure it has passed – if so it then has to be unloaded on the system; it then gets scanned by the staff member who then packs it and sends it into the Autoclave Area where it gets scanned again onto the autoclave trolley; when the trolley is full it gets scanned into the autoclave; when it’s finished it gets unloaded on the system then it goes into despatch after it’s cooled, where it is labelled up; then the sets get loaded onto a buggy via the HESSDA system – when the buggy is full it gets despatched on the system to the relevant theatre.[^]

It is important to have these systems in place so you are able to track the sets every step of the way. You know where it is at all points of the Department, so if the theatres ring up and ask where a set is or how long it will be you should be able to tell them with a good degree of accuracy, because if they give you the name or number of the set you can type it into the ‘Locate’ section of HESSDA and it will tell you where it is.[^]

It is possible to non-conform any sets or instruments at any stage of the process stated above, which means if there is a problem in the Packing Room with a set (for example, if it’s dirty or not disassembled properly) you can non-conform it back into the Wash Room where it can be scanned onto a carriage and start again. The management can use this system to monitor how much work the staff are doing and what sets they are having problems with – for example, if a staff member keeps forgetting to take an instrument apart they can be told about it so it doesn’t keep happening. When you have major problems like a washer carriage failed the washer cycle, the whole carriage can be failed and sent back to the Wash Room and the same goes for the autoclaves – if one fails it can be failed and sent back into the Packing Room to be re-wrapped.[^]

There are a couple of consequences if the system isn’t followed: the worst one is if a set or trolley is scanned into the wrong autoclave cycle – like if someone forgot to change from a pre-heat cycle to the porous load cycle – and it was dispatched and nobody noticed then it wouldn’t be sterile so you would have to recall the whole batch, but if the system wasn’t in place you wouldn’t know what batch to recall and then patients’ lives would be at risk because the sets would not be sterile. The other reason for the system is so when the Auditors check the records for the whole department every month they can see the Department is complying with industry standards and we are fit for purpose. If a set had been sterilised correctly, but hadn’t been scanned into an autoclave, but still sent over to theatre and was used in an operation then a vital step would have been missed because when you unload from the autoclaves on the HESSDA system and you try and scan into a buggy it says on the system with a very loud noise saying “No record of autoclaving”; if it got used in an operation and something went wrong then the chain of custody of the set would be looked at to see who is not doing their job right. There is also a good chance that if a patient got an infection and died – or lived and started a legal battle – then Sterile Services would be shut down pending an investigation and all the work would be sent up to Derriford along with the staff until it was resolved causing huge amounts of disruption to patients, theatres and staff.[^]

When I went out on the lorry with the Driver we first went to Tower Theatres. I found it a very confusing maze of corridors and lifts but at the back of the theatres was a very small, long corridor with metal trolleys outside each theatre with the used sets on them. When we got off the lift we had to open the empty buggy, put on some blue disposable gloves and move each trolley to the buggy and put the sets from them into the buggy. Then we went back down the lifts and corridors to the lorry and loaded the buggy onto it. We then went round to Trauma Theatres – there is much more room to move in Trauma, we had to sweep the area for buggies and decant them into one buggy to save multiple trips. We then returned to the lorry and loaded that buggy. Finally, we went back up to Cardiac Cath Lab to their sluice room which was locked with a combination lock only authorised staff can access. The sets were placed out the way on a table in that room, they were in a sealed bag we carried back to the lorry; we then drove back to SSD and unloaded the lorry.[^]