Ensuring reusable equipment meets patients’ needs and infection prevention guidelines

Authors

Joan Goodbody, BSc, RGN; Melanie Gallo, BSc, RGN; both are infection prevention and control nurses, University Hospitals Coventry and Warwickshire Trust.

When the new build at University Hospitals Coventry and Warwickshire (UHCW) Trust was opened in 2006, the commodes used were deemed not fit for purpose. They did not fit correctly over the toilets, which differed in height and width; so body fluids spilled onto the floor spillages onto the floors, and they were rusting – this may have been caused by the disinfectant used to decontaminate them.

Universal precautions suggest all blood and some body fluids are potentially infectious (Ayliffe et al, 2000). Therefore, the clinical environment at UHCW was at risk of contamination from micro-organisms every time one of the commodes was used over a toilet. Body fluid spillage onto the floor can compromise patients’ dignity as well as exposing staff to unnecessary risk.

As part of the compliance criteria in the Health and Social Care Act (Department of Health, 2009), service providers must prevent occupational infection and protect staff from exposure to infections that are communicable. Thus, use of these commodes could be viewed as a breach of the Act.

Background

Any equipment that is shared between patients must be decontaminated appropriately following each use (Pratt et al, 2007)  and outbreaks of infection can be associated with incorrect decontamination of equipment (Rampling et al, 2001). Commodes used by patients with Clostridium difficile infection should be cleaned with agents that contain at least 1000ppm of chlorine (DH and Health Protection Agency,2008). As rusting of the existing commodes was evident and the disinfectant used by the trust was not listed in the manufacturer’s guidance, it was felt an alternative commode that would fit over all existing toilets and could be decontaminated with 1000ppm of chlorine solution was required. 

Purchasing new equipment

National guidance and evidence-based guidelines on decontamination of equipment must be considered when purchasing new equipment for hospital use.Any company that supplies the NHS with reusable equipment, such as commodes, must first provide decontamination guidelines (Medicines and Healthcare Products Regulatory Agency, 2006).The guidelines provided  must be taken in to account by any organisation before purchasing new equipment MRHA (2001).

The Department of Health (2009) states manufacturers’ guidance should be followed when decontaminating reusable medical devices.If trusts do not comply with manufacturers’ decontamination instructions and the equipment is damaged by untested disinfectants, safety may be compromised and the guarantee may be void. 

Decontamination considerations

Chlorine releasing agents – as recommended by Department of Health and Health Protection Agency (2008) for cleaning commodes used by patients with Clostridium difficile – may not be compatible with all equipment. UHCW already decontaminated commodes with 1000ppm of chlorine, however the IPCT had to ensure that any company supplying new models listed the product as compatible.

The option of placing some components of the new commode chairs through a thermal disinfector was also considered as a means of achieving high level disinfection. The IPCT stipulated to potential suppliers that this must be incorporated into decontamination guidelines.

Search for a commode

After considering these factors, the IPCT decided to test thechair commode from Roma Medical. This already had many positive features, including an antimicrobial coating.

The commode was taken to two wards to test but it did not fit correctly over the toilets. It became apparent that, due to the design of the toilets, no standard commode was going to fit and a bespoke design was required. The IPCT also felt that the commode should be modified to reduce the number of dirt traps making it easier to clean and disinfect.

Design modifications

The IPCT worked in collaboration with the commode manufacturer to make a number of changes to the design. These included:

• Reducing the depth of the chair to allow the commode aperture to locate centrally over the hospital toilets;
• Increasing the height to allow the commode to clear all toilets when fitted with a bedpan rack;
• The development of a removable footrest for ease of cleaning;
• Redesigning the armrests as a single unit to remove dirt traps;
• Reaching agreement with the manufacturer of the thermal disinfector used at the trust so parts of the commode could be deep cleaned in its washer.

Trial and evaluation

Once decontamination guidelines had been agreed and the commode modified according to specifications, a prototype was developed. This was given to the orthopaedic wards to trial and evaluate for two weeks. In line with MRHA (2006) guidance, a senior nurse was given instructions on how to dismantle and reassemble the equipment to enable effective decontamination. These instructions were then cascaded to other staff members.

At the end of the trial period, evaluation forms were completed (see box 1). This resulted in a modification to the foot rest bar at the request of an occupational therapist, who asked for it to be moved back slightly to enable optimal handling and moving technique. Following further assessment by the occupational therapy and physiotherapy therapy departments, the commode received a positive evaluation.

Education and training

It is vital staff are adequately trained to use new equipment correctly and decontaminate it effectively using the correct disinfectants. The NMC (2008) states ‘that nurses must be involved in appropriate training that will maintain and develop competence and performance’. It is a requirement of the Health and Social Care Act 2008 (DH, 2009) that staff are educated to prevent and control healthcare associated infections.

Once the final design of the commode was agreed and re-evaluated in practice, the manufacturers undertook a robust training programme to educate staff on how to use the commode safely and how to dismantle and reassemble it to enable adequate decontamination. To ensure that the commodes are being decontaminated correctly, the manufacturer has agreed to undertake yearly commode audits at UHCW.

Conclusion

UHCW now has a commode that promotes patients’ dignity and can be decontaminated easily – thus reducing the risk of cross infection and ensuring staff are not put at risk by exposure to body fluids. This has been achieved by following national guidance and evidence-based guidelines, and by working closely with a manufacturer to make the necessary modifications. In the experience of the IPCT, most companies will work with a trust to meet its needs if a problem with a product is identified.

This work has underlined the importance of following decontamination guidelines provided by the manufacturer and the importance of checking compatibility of disinfectants when purchasing new equipment for patient use. This not only protects the warranty of equipment but also reduces the infection risk to patients and staff.

It has also demonstrated the importance of evaluating new products in practice and working with manufacturers and other members of the multidisciplinary team to ensure the product is fit for purpose.

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