Connaissances et pratiques des étapes préalables à la stérilisation des dispositifs médicaux thermorésistants : Etude au Centre Hospitalo-Universitaire Sahloul, Sousse-Tunisie - 2022

OBJECTIVES

The standard process of central sterilization is crucial for the optimal functioning of the operating room. The outcome of this process is closely linked to the steps preceding the steps prior to the sterilization step itself. These steps include pre-disinfection carried out in the operating rooms and other stages, namely washing, drying and packaging, which must be performed in the central sterilization unit. In this context, this study aimed to describe the knowledge of the staff in the operating rooms and the central sterilization unit at Sahloul University Hospital in Sousse (Tunisia) in 2022, regarding the steps prior to the sterilization of reusable thermoresistant medical devices and to describe their practices in terms of compliance with these steps.

METHOD

A descriptive study was conducted from January 2022 to June 2022 with the aforementioned staff, using a self-administered questionnaire to assess their knowledge of the pre-sterilization steps and a direct observation audit of their practices with regard to these steps. Both measurement instruments were pre-tested.

RESULTS

Out of 102 self-administered questionnaires (knowledge assessment) distributed to the staff concerned, only 80 were returned and correctly filled out, giving a response rate of 78.4%. Participants' responses regarding the order of steps prior to the sterilization were incorrect in 64% of cases. With regard to the evaluation of professional practices, 224 observations were made in the study area (practice audit). In 82% of these observations, the pre-disinfection step was confused with the washing step. The use of Betadine brushes and scrubbing pads for device washing was noted in 89.3%, along with the absence of swabbing of the canals and hollow parts in 9.4% of cases and the absence of drying of the canals with compressed air.

CONCLUSION

Mastery of the steps prior to sterilisation of reusable thermoresistant medical devices was insufficient in our institution, suggesting the importance of reinforcing the implementation of the procedure through a continuous training program followed by action plans.

[Individual traceability to the instrument: Evolution of laser and micropercussion markings over the sterilisation cycles]

In order to implement individual instrument traceability, the evolution of laser and micropercussion markings was evaluated over 250 sterilisation cycles. A datamatrix associated with its alphanumeric code was applied on three types of instruments by laser or micropercussion. All instruments had a unique identifier affixed by the manufacturer. The sterilisation cycles corresponded to the usual cycles performed in our sterilisation unit. The laser markings had very good visibility but were quickly affected by corrosion: 12% of the markings were corroded after the 5th sterilisation cycle. Similar results were observed for unique identifiers applied by the manufacturer but with visibility attenuated by sterilisation cycles: 33% of identifiers were poorly visible after the 125th sterilisation cycle. Finally, micropercussion markings were less susceptible to corrosion but initially showed poorer contrast.

[Recommendations of the Committee of Andrology and Sexual Medicine of the AFU concerning the management of Vasectomy]

OBJECTIVES

To answer the main clinical questions asked by practitioners and men consulting for a vasectomy request.

METHOD

The CPR method was used. The clinical questions were formulated according to the PICO methodology. A Pubmed literature search for the period 1984-2021 identified 508 references, of which 79 were selected and analyzed with the GRADE grid.

RECOMMENDATIONS

Vasectomy is a permanent, potentially reversible contraception. It is a safe procedure. A second vasectomy is necessary in only 1 % of cases. Surgical complications (hematoma, infection, pain, etc.) are rare. The frequency of prolonged scrotal pain after vasectomy is about 5 %, and less than 2 % describe a negative impact of this pain on their quality of life. Vasectomy does not have negative consequences on sexuality. The only contraindication to vasectomy is the minor patient. Patients at increased risk of remorse are single, divorced or separated men under the age of 30. Sperm storage may be particularly appropriate for them. Whatever the reason, the law allows the surgeon to refuse to perform the vasectomy. He must inform the patient of this at the first consultation. The choice of the type of anesthesia is left to the discretion of the surgeon and the patient. It must be decided during the preoperative consultation. Local anesthesia should be considered first. General anesthesia should be particularly considered in cases of anxiety or intense sensitivity of the patient to palpation of the vas deferens, difficulty palpating the vas deferens, or a history of scrotal surgery that would make the procedure more complex. Concerning the vasectomy technique, 2 points seem to improve the efficiency of the vasectomy: coagulation of the deferential mucosa and interposition of fascia. Leaving the proximal end of the vas deferens free seems to reduce the risk of post-vasectomy syndrome without increasing the risk of failure or complications. No-scalpel vasectomy is associated with a lower risk of postoperative complications than conventional vasectomy. Regarding follow-up, it is recommended to perform a spermogram at 3 months post-vasectomy and after 30 ejaculations. If there are still a few non-motile spermatozoa at 3 months, it is recommended that a check-up be performed at 6 months post-vasectomy. In case of motile spermatozoa or more than 100,000 immobile spermatozoa/mL at 6 months (defining failure), a new vasectomy should be considered. Contraception must be maintained until the effectiveness of the vasectomy is confirmed.

[Vaginal tubal sterilization: About a series of 158 patients from 2005 to 2021]

OBJECTIVES

The latest recommendations of 2006 on tubal sterilization reported an infectious risk of 1.5 to 2.5% for the vaginal approach. There is, however, limited literature on this approach. The primary objective of our study was to investigate the feasibility of tubal sterilization via posterior colpotomy. The secondary objectives were to study the reproducibility of this approach, the postoperative infection rate after tubal sterilization via posterior colpotomy, to evaluate its peroperative and postoperative morbidity.

METHODS

This retrospective study, conducted at the Antibes's Hospital, included patients over 18 years of age who underwent tubal ligation with clips or bilateral vaginal salpingectomy from 2005 to 2021.

RESULTS

We included a total of 158 patients: 88% by clips and 12% by bilateral salpingectomy. The average operative duration was of 27 minutes. There were no infectious or postoperative complications directly related to the sterilization. There were two failures of the technique, requiring conversion to laparoscopy (1.3%) and four subsequent pregnancies (2.5%).

CONCLUSIONS

We were able to show low morbidity and failure rates with this surgical technique. It, therefore, does not appear to be inferior to the laparoscopic approach. Moreover, it is reproducible technique.

[ISO 9001 quality approach in Sterilization Unit and developing the skills of agents: Contribution of a multi-support, transdisciplinary and multi-professional training plan]

OBJECTIVES

The Sterilization Unit of the Narbonne Hospital Center (France) has decided to embark on a process of NF EN ISO 9001: 2015 certification. The objective is to describe how the working group has appropriated the provisions relating to staff training in order to build a skills development plan for its Sterilization agents.

METHODS

A multi-professional working group has been set up. After a preliminary inventory, an inventory of skills needs, expectations of the agents, available means, and a bibliographical research, the group drew up a training plan with the support of a quality engineer from the Hospital Centre. The training plan was validated by a review of the management of the establishment.

RESULTS

Several teaching aids were chosen: a serious game developed by the working group, the planning of instrumentation sessions, quality meetings and feedback committees. The principle of transdisciplinarity and recourse to multi-professional exchanges is the common thread in the elaboration of the training plan.

CONCLUSION

The use of the selected materials is formalised in the form of a skills development plan indexed in the institution's quality management system. The application of the requirements of the ISO 9001 standard in terms of training in our Sterilization quality management system enables risk control and continuous improvement of the training plan to comply with technical and regulatory changes in the profession.

Effects of cold chemical (glutaraldehyde) versus autoclaving sterilization on the rate of coating loss of aesthetic archwires: A double-blind randomized clinical trial

OBJECTIVE

The effect of any sterilization methods (cold chemical, or hot) on film removal from coated archwires has not yet been investigated. Thus, we assessed it.

MATERIALS AND METHODS

This double-blind randomized clinical trial was performed on 120 observations: 40 macroscopically intact coated archwires from 4 brands were purchased (n=10 archwires/brand). Five wires from each brand underwent cold and 5 underwent hot sterilization. Wires were applied in 40 non-extractions patients at alignment phase of treatment (one month). Afterwards, 3 inter-bracket segments from each wire were examined microscopically, and the percentage of coating loss was recorded for each segment. Coating losses of the 4 brands and 2 sterilization methods were compared using a two-way ANOVA and a Welch t-test (α=0.05). Surfaces were also evaluated using scanning electron microscopy.

RESULTS

The mean surface coating loss of hot (autoclave) and cold (glutaraldehyde) sterilization methods was 25.6±28.7 and 28.1±30.8 percent respectively. The mean surface coating removal of the Ortho Organizers, American Orthodontics, SIA, and Gestenco brands were 24.1±28.4, 36.7±36.0, 23.0±24.4, and 23.6±28.0 percent, respectively. The two-way ANOVA indicated a lack of overall significant differences among wire brands (P=0.189) and between sterilization types (P=0.629). However, the interaction of sterilization and brands was significant (P=0.005).

CONCLUSIONS

Within the limitations of this 1-month clinical trial limited to 4 coated NiTi archwire brands only, the average coating removal of examined brands might not differ much, amounting to about 26% within a month. Glutaraldehyde and autoclave sterilization might not affect the average speed of coating loss in all brands, although each sterilization method might be favourable for certain brands.

[Reevaluating the shelf life of sterilized packaged items via a risk-analysis study]

In the hospital, all the reprocessed reusable medical devices (RMD) are conditioned with a sterile barrier system and a protection package and they expire after three months. The objective of this study is to reevaluate this shelf life via a risk-analysis study focusing on the steps whose malfunction can fail RMD sterility. The first step is analysing current conditions of packaging, transportation and storage of RMD. The risk-analysis study has been built on French National Authority for Health template. Risks are prioritized in three categories: non critical risks, risks that need to be kept track of and risks to manage as a priority. Storage conditions have been evaluated in 52 wards in ten different structures. All of the wards respect the paper side of the pouches. They were stored in a dedicated storage unit in 85 % of the units. They were closed at the moment of the observation in 58 % of the cases. RMD were stacked in 81 % of the units and 36 % of them had at leat one expired RMD in their storage unit. The risk-analysis study identified two risks to manage as a priority. Some RMD were damaged during transportation to a subcontractor hospital. This step is barely manageable due to the human factor but the transport rules have been reminded in order to lower the risks on the materials. The operating rooms common storage include shelves that alter pouches and wraps, but a replacement of equipments is under discussion. Thanks to a better understanding of RMD circuit current conditions, allowing a better control of sensitive steps, their shelf life is reevaluated up to 6 months for containers and 4 months for other pouches.

[Developing of an integration and training course for sterilization agents]

Until September 2018, there was no formal training or evaluation for sterilization agents at Nancy's hospital (CHRU). The goal was to create a formalized training path, to record the training and the evaluation of an agent using a written support. All the training resources available in the service have been identified and the missing tools have been created. A typical induction period has been created. It is divided into large parts: a welcome week followed by several weeks of training. The welcome week consists of observing all the activities of the service. The following training is divided into two parts. It begins with a theoretical training followed by 12weeks of practical training. The next 12weeks are dedicated to develop their knowledge. Follow-up is ensured through theoretical and practical evaluations, a grid of activities to be mastered completed as and when learning and a monitoring sheet on which are formalized weekly interviews with the pharmaceutical team. Finally, a logbook has been created and brings together all the useful documents for an agent throughout his career as a sterilization agent. The aim of the training path is to guide and involve the new agents, from their arrival in sterilization service to their continuous training, and to standardize the professional practices. It remains to be seen whether the tools put in place improve the knowledge and skills of the staff.

Evaluating the effect of clinical usage and autoclave sterilization on the load deflection properties of three different orthodontic wires: Ex-vivo study

OBJECTIVE

The aim of this study was to evaluate the effect of intraoral aging and sterilization on the physical properties of rectangular Nickel-Titanium (NiTi), Beta-Titanium and Cooper NiTi (Cu-NiTi) arch wires.

METHODS

Three types of preformed 0.018×0.025 inch wires: super elastic NiTi wire, Beta-Titanium wire and Cu-NiTi wire (20 of each type) were divided into 4 groups: as-received (T0), autoclave (T1), intra oral aging after sterilization (T2) and intra oral aging (T3). Specimens in T2 and T3 groups were used in oral environment of 30 participants for 8 weeks. In the next step a length of 30mm was cut from both ends of each arch wire, and 120 straight specimens were achieved and tested by Instron for evaluating their load deflection properties. Data were analysed by means of One-way ANOVA and Tukey's (honestly significant difference) HSD tests.

RESULTS

In NiTi wire, all conditions led to a significant decrease in deactivation mean load compared with control in most deflections (P=0.000). In Cu-NiTi wire, all conditions led also to a significant decrease in deactivation mean load compared with the control (P=0.000). In Beta-Titanium wire, sterilization had no significant effect on the load deflection properties; but significant increase was observed in T2 (in all deflections) and T3 (in 1.8-1mm) compared with the control.

CONCLUSIONS

After all conditions, NiTi wire in spite of reduction in stiffness presented a mean load which stayed in category of heavy force. The Cu-NiTi wires saw an improvement in light physiologic force. In contrast, the Beta-Titanium stiffness increased after clinical usage, and the force level remained in the range of heavy force.

[ISO 9001 certification of a sterilization unit: Transition to the 2015 version]

OBJECTIVES

The sterilization unit of Pitié-Salpêtrière-Charles Foix hospital group is ISO 9001 certified on one of its sites. The purpose of this work is to describe how the unit prepared for the transition from the 2008 version to the 2015 version of the standard, as well as the conduct of the audit.

METHODS

The pharmaceutical team has received prior training from French national organization for standardization (Afnor) to understand the new requirements and how to apply them to the sterilization unit. SWOT and PESTEL methods were used. A 3-month retro planning has been established. Deadlines were the annual management review and the certification audit. Audits carried out by the Quality and Risk Management Department helped to identify the priorities.

RESULTS

The compliance of the quality management system (QMS) has led to the identification of internal and external challenges, relevant stakeholders and risks and opportunities. Management leadership and communication has been strengthened and control over external providers has improved. The auditor did not identify any non-compliance, but said that the system had to mature regarding the recent application of the new requirements.

CONCLUSIONS

The QMS is more effective, new strengths and weaknesses have been identified and requirements of the unit and stakeholders have been better defined. The pharmaceutical investment necessary for this approach has been important. Involvement in the quality approach of all the staff of the unit lies to the success of the project.

[Subcontracting a steam sterilization activity: Impact on surgical instruments]

Subcontracting our institution's sterilization activity induced the implementation of an automated cleaning facility. Following this development, some of the resterilizable stainless steel needle holders started to show abnormal corrosion. Our study goal was to investigate the causes of this corrosion in order to optimize the sterilization circuit. A full sterilization process mapping and Ishikawa diagram enabled us to identify potential causes of corrosion. The needle holders' intrinsic characteristics, like steel quality and manufacturing, were analyzed as well as extrinsic factors such as the influence of preprocessing soaking conditions, steel passivation, water quality and the impact of corrosion inhibitors. Each potential factor of corrosion was tested in real conditions on needle holders' kits. The needle holders steel grade complies with medical standards and the tests showed that passivation and pre-processing conditions were not involved in the occurrence of corrosion, contrary to soaking length and use of softened rinsing water, containing more chloride than reverse osmosis water, and, thus conducive to rust formation. Moreover, corrosion inhibitors were deemed ineffective or incompatible. Due to this analysis, the incidence of corrosion was reduced by switching softened water to osmosis water and by introducing dynamic drying in the automated cleaning process. In addition, this work stresses the importance of minimizing waiting times and auditing the sterilization circuit before any subcontracting. Management Guidelines related to sterilization's outsourcing would probably have helped to limit this episode.

[Evaluation of satisfaction after hysteroscopic tubal ligation. About a study from the CHU of Besançon]

OBJECTIVE

The Essure(®) system is a hysteroscopic sterilization method. The purpose of our study was to retrospectively evaluate the sterilization procedure with Essure(®) devices without anesthesia.

PATIENTS AND METHODS

The descriptive study included all tubal sterilizations with Essure(®) devices performed without anesthesia, with MEOPA, from January 1st, 2013 till February 28th, 2014 in the CHU of Besançon. The evaluation of the global satisfaction of the patients was collected by telephone survey.

RESULTS

A hundred and forty-three patients benefited from Essure(®) without anesthesia during the period of study in the CHU of Besançon and among them, 120 patients answered the telephone survey questionnaire. The average age was of 41.3 years. As regards the satisfaction and the tolerance, 89.2% of the patients declared to be globally satisfied by this procedure and 95.8% would recommend it to a friend. Indeed, 66.6% of the patients declared to have felt no pain or moderate pain. Furthermore, the MEOPA was well tolerated at 79.9% of the patients. As regards the procedure of Essure(®) inserts without anesthesia the rate of failure was 9.2% and at 3 months the radiological control was satisfactory in 94.5% of the patients.

DISCUSSION AND CONCLUSION

The tubaire sterilization by implants Essure(®) is a fast and effective procedure. Our study shows, that at present, this technique can be realized without anesthesia, during a dedicated consultation, with an important rate of global satisfaction of the patients. It thus allows to decrease the number of hospitalization in ambulatory surgery and to decrease the cost of this intervention.