Marketing Director, Vernacare, UK.
Healthcare providers are under increasing pressure in today’s society - populations are expanding at an unprecedented rate and many people are living longer. With demand for the services on the rise, hospitals strive to meet their patients’ needs and expectations for high-quality treatment, without compromise. However, the risk of Healthcare-acquired Infections (HCAI’s) is a prevalent global issue, and is a real challenge for hospitals to overcome.
According to the World Health Organisation (WHO), hundreds of millions of patients are affected by healthcare-associated infections worldwide each year, leading to significant mortality and financial losses for health systems. Of every 100 hospitalised patients at any given time, 7 in developed and 10 in developing countries will acquire at least one healthcare-associated infection.
The level of infection contraction amongst patients in hospitals cannot be ignored. In June 2014, the Indian Journal of Critical Care Medicine published an article on the importance on preventing hospital-acquired infections, ‘a constant threat to hospitalised individuals’. Also, in Singapore, doctors questioned regarding the issue have estimated that one in seven patients acquire an infection on the hospital ward, leading to prolonged illness, extra incurred costs and even death. Newborn babies are especially at high risk from HCAIs in some countries, for example in Southeast Asia where HCAIs are responsible for 75 per cent of all causes of death in the neonatal period.
The management of human waste is recognised as a high risk for transmission of infections in healthcare environments. Pathogens of particular concern in the hospital setting include: Clostridium difficile (C.difficile), Carbapenem-Resistant Enterobacteriaceae (CRE), Vancomycin-Resistant Enterococci (VRE), Multi Drug-resistant Gram-negatives (MDR Gram-negatives), Meticillin-resistant Staphylococcus Aureus (MRSA) and Norovirus. C. difficile infection is usually spread via the hands of staff and those who come into contact with infected patients or with environmental surfaces like floors, bedpans and toilets that have been contaminated with the bacteria or its spores. The bacteria and spores are extremely hardy, and some pathogens can survive on dry surfaces such as clothes and environmental surfaces for months.
Items that become contaminated with human faeces, such as bedpans, are categorised as non-critical devices defined as items that come into contact with intact skin, as opposed to critical items that enter sterile tissue or the vascular system. As a result, surprisingly little attention appears to be paid to the risks of disease transmission and environmental contamination, both of which are particularly likely to occur during diarrhoea episodes. Safe management of human waste therefore has the potential to reduce HCAI through the employment of better hygiene and infection prevention measures.
There are a number of chemical, physical and mechanical toileting aids and human waste disposal solutions in healthcare environments for immobile patients. These include:
Practices with regard to human waste disposal in healthcare environments vary in different parts of the world:
But the most common practice worldwide is reusable plastic containers reprocessed in washer disinfectors. Below is an analysis of each practice:
It has been found that the often commonly accepted practice of manual washing poses extremely high health risks to both patients and healthcare workers. A survey undertaken by the International Federation of Infection Control (IFIC), showed that when bedpans are cleaned manually, 44 per cent of the time it is done in the patient’s bathroom. Manual cleaning typically involves just rinsing or spraying with cold water, often using bedpan sprayers or ‘wands’, which results in splashing and the aerosolisation of faecal material. This also causes visible splashes and splatters on hands and surrounding items.
There is also a lack of standardisation in validation, testing and monitoring of methods, particularly with regard to effectiveness. Disinfection is often carried out without the observation of correct procedures, if it is carried out at all. Survey findings from Belgium, Canada and the US found that even though healthcare workers were aware of the advisory from the WHO Infection Prevention and Control (IPC) that bedpans have to be cleaned and disinfected after each use, nurses often only do it with water because of their workload, only sometimes following up by wiping or spraying with disinfectant. This cleaning method fails to fully eliminate bacterial and spore loads and is believed to be a contributing factor for increased C. difficile infections. A Canadian study showed that the infection rate dropped by as much as 50 per cent when a disposable bedpan system and other interventions were introduced. In addition, MRSA rates also dropped by 30 – 50 per cent.
2. Reusable Bedpans and Utensils that are Reprocessed in Washer Disinfectors
The reusable bedpan washer system is used in combination with plastic and stainless steel bedpans and urinals used for patient toileting. Pre and full washes last for an average of 5-8 minutes, with pre-wash and rinses using hot and cold water before being washed between 80-85 degrees for 60 seconds. Thermal disinfection and detergents are required to reduce the load of pathogens to a level thought to be safe given the Spaulding classification of ‘low’ risk. The benefits of this system include the one-off capital and installation costs, with limited consumable costs thereafter, and a standard operating procedure that ensures continuous monitoring when fitted to the machine. It can be used to clean a range of utensils other than bedpans, and ensures low exposure of chemicals to healthcare workers.
However, a recent study found that 7.6 per cent to 33 per cent of reusable items failed an audit due to visible faecal soiling after processing in a bedpan washer disinfector. Even though heat and disinfection might reduce pathogens, another study found that “the current accepted thermal decontamination parameters for all bedpan washer disinfectors (i.e. 80?C for one minute) are not adequate to eliminate C. difficile spores from bedpans”. Inadequate disinfection of bedpans was also associated with cross-infection by VRE. and has also been linked with transmission of VRE. There is a possibility of recontamination as soon as the item is removed from the machine if procedures are inadequate. Reusable bedpan washers also require periodic validation as well as revalidation following repair or servicing. Some have a lack of warning systems when the machine is not functioning correctly, giving rise to ineffective functioning if detergent or rinse aid run out.
Single-use systems comprise the use of a disposal unit and single-use paper-based utensils. The single-use items are broken down into a fine watery slurry using only cold water. Each cycle takes two minutes, reducing instances where there is the potential for a stockpile of soiled bedpans and waste matter is left to dry and solidify, leaving residual soil even after the wash and disinfection cycle.
From an engineering standpoint, the time spent on maintaining disposal units is half of that required to maintain washer disinfectors, and when all costs are considered, single-use systems can be up to 39.4 per cent cheaper to maintain than alternative systems.
There are comparable benefits to both washer disinfector and single-use systems, but due to the high risk of HCAIs to both patients and healthcare workers, the choice for toileting aid and human waste management solutions and systems in healthcare facilities needs to be carefully considered. Both systems require training and can still be subject to the risk of operator error. Even though the use of reusable bedpan and utensils reprocessed in washer disinfectors has been a widely-accepted practice, the fact is that the currently accepted thermal decontamination parameters, such as 80?C for one minute, are simply not adequate to eliminate C. difficile spores and VRE from bedpans.
Single-use products (such as Vernacare’s) are manufactured using excess and otherwise wasted clean newspaper. No bleach colouring is added, ensuring products are as environmentally-friendly as possible, and the biodegradable slurry is then safely washed down the drain. Single-use disposable systems have been proven to increase patient and healthcare worker safety by contributing to the reduction in C. difficile infections by as much as 56 per cent, thus breaking the chain of infection. As part of a portfolio of infection control and waste management measures, such disposable systems can help save nurse time and improve working conditions. This in turn helps to preserve patient dignity and enhance the patient experience by providing a clean product every time to aid safer healthcare.
6) Spaulding EH. Chemical disinfection of medical and surgical materials. In: Lawrence C, Block SS, eds. Disinfection, sterilization, and preservation. Philadelphia: Lea & Febiger, 1968:517-31.
7) The Canadian Journal of Infection Control, Vol. 26 No.3 Fall 2011, http://www.ipac-canada.org/cjic/vol26no3.pdf
8) IFIC survey on global practices related to disposal of faeces and urine, Walter Popp, 12 March 2014
9) IFIC survey on global practices related to disposal of faeces and urine, Walter Popp, 12 March 2014
10) A. Tomiczek et al Healthcare Quarterly, 9(Sp) October 2006: 50-53.doi:10.12927/hcq.2013.18459
Identifying and Reducing Risks: Enhancing Patient Safety through the Management of Clostridium difficile at Toronto East General Hospital
11) (Bryce E, Lamsdale A, Forrester L, et al, Bedpan washer disinfectors: An in-use evaluation of cleaning and disinfection. American Journal of Infection Control. Oct 2011, 39:566-70)
12) Alfa MJ, Olson N, Buelow-Smith L. Simulated-use testing of bedpan and urinal washer disinfectors: evaluation of Clostridium difficile spore survival and cleaning efficacy. Am J Infect Control. Feb 2008; 36(1):5-11
13) Systematic review, Woodford N. et al, Clinical Microbiology Review Reviews (1995) 8(4) 585-615
14) Hickman B J Inst Hosp Eng (1989) 43(1) 14-17
15) Power M., Wigglesworth N., Donaldson E., Chadwick P., Gillibrand S., Goldmann D. Reducing Clostridium difficile infection in acute care by using an improvement collaborative. BMJ 2010; 341:c3359
Emma Sheldon is Global Marketing Director for Vernacare, a medical products manufacturer and leading infection control organisation. Emma is responsible for leading sales and marketing activities across 48 countries and has experience working in partnership with patients and healthcare providers to develop and bring to market innovative infection prevention products.