ATP Bioluminescence for Assessing the Efficacy of the Manual Cleaning Procedure during the Reprocessing of Reusable Surgical Instruments

Multisociety guidance for sterilization and high-level disinfection

SHEA, in partnership with ASGE, APIC, AAMI, AORN, HSPA, IDSA, SGNA, and The Joint Commission, developed this multisociety infection prevention guidance document for individuals and organizations that engage in sterilization or high-level disinfection (HLD). This document follows the CDC Guideline for Disinfection and Sterilization in Healthcare Facilities. This guidance is based on a synthesis of published scientific evidence, theoretical rationale, current practices, practical considerations, writing group consensus, and consideration of potential harm when applicable. The supplementary material includes a summary of recommendations. The guidance provides an overview of the Spaulding Classification and considerations around manufacturers' instructions for use (MIFUs). Its recommendations address: point-of-use treatment prior to sterilization or HLD, preparation of reusable medical devices at the location of processing, sterilization, and immediate use steam sterilization (IUSS), HLD of lumened and non-lumened devices, processing of reusable medical devices used with lubricating or defoaming agents, monitoring for effectiveness of processing, handling of devices after HLD, augments and alternatives to HLD, processing of investigational devices, tracking of reusable medical devices, and approaches to implementation.

Improving the cleaning quality of tube lumen instruments by imaging analysis and deep learning techniques

OBJECTIVES

The complex structure of tube lumen instruments (TLIs) makes them more difficult to clean compared to solid instruments. This study aims to improve the cleaning quality inspection of reusable TLIs, ensuring patient safety and clinical reliability.

METHODS

This study improves the inspection of TLI cleaning quality using imaging analysis and deep learning techniques. Internally cleaned TLIs were imaged using an electronic endoscope by clinical staff, and the resulting images formed the original dataset. To enhance the quality of the TLI images and augment the dataset, image preprocessing techniques such as enhancement, slicing, and threshold filtering were applied. Based on the sliced image dataset, baseline models with relatively better performance were selected by comparing the performance of multiple deep learning models in TLI image classification. To further improve the model's performance, two attention mechanisms were introduced to focus on important features.

RESULTS

The optimized model outperforms the baseline model in both performance and stability. Specifically, the FA-ResNet18 model with the concurrent space and channel squeeze and excitation (scSE) attention mechanism performs the best, with accuracy, macro precision, macro recall and macro F2 metrics all exceeding 98.3 %.

CONCLUSIONS

This method can effectively reduce the risk of errors caused by subjective factors and visual fatigue in manual inspection.

Hygiene Assessment of Buffalo Milking Parlours in Campania Region, Italy: A Preliminary Study by Using ATP Luminometry and Bacteriological Investigation

Careful cleaning of a milking parlour and its equipment is fundamental to guarantee good raw milk quality and prevent the dissemination of bacteria and improve animal welfare. This study aimed to investigate, using an ATP-bioluminescence assay and bacteriological analysis, the bacterial contamination of milking parlours on milking parlour surfaces of buffalo farms in the Campania Region, evaluating the seasonal dynamics during the year 2022. Eight farms were selected by the Italian ClassyFarm system, which assesses the level of animal welfare and biosecurity according to risk analysis. Before sampling, all dairy farm owners filled out a questionnaire on milking management, animal hygiene, and health. The questionnaires evidenced similar cleaning procedures but an absence of a standardised cleaning protocol among the different farms. ATP bioluminescence results evidenced similar levels of contamination in all the selected buffalo farms, and the season comparison showed no significant differences. A variation in the percentages of bacterial isolates during the different seasons was observed, with a higher prevalence of Enterobacteriaceae (38%) in summer. A small number of samples exhibited an absence of bacterial growth. Identifying bacteria is crucial for understanding the microorganisms present in the milking parlour, yet employing ATP luminometry could offer broad and accurate applications in buffalo milking parlours. In conclusion, the use of ATP bioluminescence for evaluating the hygiene of a buffalo milking parlour could represent a further important advancement in dairy farming technology.

Comparing contamination rates of sterile-covered and uncovered transducers for ultrasound-guided peripheral intravenous lines

INTRODUCTION

Physicians frequently use point-of-care ultrasound for intravenous access and bloodwork in the ED. Recently, AIUM and ACEP released recommendations on ultrasound-guided peripheral intravenous lines (USPIVs), but there are no agreed upon standardized policies. We sought to determine whether the use of sterile-covered transducers (SCT) decreases the rate of contamination when compared to uncovered transducers (UCT) after standard low-level disinfection (LLD).

METHODS

This is a randomized control trial comparing contamination rates of US transducers between SCT and UCT after their use for USPIV by the vascular access team, also known as the "PICC" team, over a 3-month period. A sample of admitted patient with an USPIV order were included and randomized to SCT (experimental) or UCT (control) arms. Transducers were swabbed and inserted into the SystemSURE Plus Adenosine Triphosphate (ATP) Luminometer to calculate Relative Light Units (RLU). We performed a cost analysis of requiring sterile covers for USPIVs.

RESULTS

The UCT and SCT arms contained 35 and 38 patients, respectively. The SCT group had a mean of 0.34 compared to the UCT group mean of 2.29. Each sterile cover costs $8.49, and over 3000 USPIVs are placed annually by the "PICC" team.

CONCLUSION

Contamination rates were similar among the UCT and SCT groups after LLD. 254 inpatient USPIVs are performed monthly, not including failed attempts or covers used in the ED where USPIV placement is an essential part of ED workflow. This study suggests that the use of SCT does not significantly affect transducer contamination rates. These findings question burdensome regulatory hospital policies that are not evidence-based.

Adenosine triphosphate (ATP) sampling algorithm for monitoring the cleanliness of surgical instruments

BACKGROUND

Timely detection of cleaning failure is critical for quality assurance within Sterilising Service Units (SSUs). Rapid Adenosine Triphosphate (ATP) testing provides a real time and quantitative indication of cellular contaminants, when used to measure surface or device cleanliness. The aim of this study was to investigate the use of an ATP algorithm and to whether it could be used as a routine quality assurance step, to monitor surgical instruments cleanliness in SSUs prior to sterilisation.

METHODS

Cleanliness monitoring using rapid ATP testing was undertaken in the SSUs of four hospitals located in the western (Amazonia) region of Brazil. ATP testing was conducted (Clean Trace, 3M) on 163 surgical instruments, following manual cleaning. A sampling algorithm using a duplicate swab approach was applied to indicate surgical instruments as (i) very clean, (ii) clean, (iii) equivocal or (iv) fail, based around a 'clean' cut-off of 250 Relative Light Units (RLU) and a 'very clean' <100 RLU.

RESULTS

The four cleanliness categories were significantly differentiated (P≤0.001). The worst performing locations (hospitals A & C) had failure rates of 39.2% and 32.4%, respectively, and were distinctly different from hospitals B & D (P≤0.001). The best performing hospitals (B & D) had failure rates of 7.7% and 2.8%, respectively.

CONCLUSION

The ATP testing algorithm provides a simple to use method within SSUs. The measurements are in real time, quantitative and useful for risk-based quality assurance monitoring, and the tool can be used for staff training. The four-tiered approach to the grading of surgical instrument cleanliness provides a nuanced approach for continuous quality improvement within SSU than does a simple pass/fail methodology.

Development of a "Scissor-Tip-Separator" for adjustment of scissor blade separation and prevention of scissor blade damage during steam sterilization

Background

Reprocess reusable surgical instruments during steam sterilization; damage occurs to sharp scissor blades in close position, so steam cannot reach the blades. Surgical instruments' management requires standards to ensure patient safety and prevent harmful pathogens, especially in the COVID-19 pandemic. Although various devices can separate scissor blades, they do not prevent damage to cutting edges. To address the above problem, we developed a new scissor protector, the "Scissor-Tip-Separator," and evaluated its efficacy.

Methods

The "Scissor-Tip-Separator" design follows the steam sterilization guideline that instrument tips must be separated. The locking handles and V groove mechanism keep the scissor blades separated while preventing damage to the cutting edges. For efficacy assessment, purposive sampling was performed to select 44 Thai perioperative nurses at Ramathibodi Hospital, Bangkok, Thailand, to evaluate the "Scissor-Tip-Separators" in 450 sterile instrument containers. All participants evaluated surgical scissors placed in the "Scissor-Tip-Separators" during instrument setup, following a problem record checklist. At the end of the fifth use, participants were asked to complete the "Scissor-Tip-Separator" Effectiveness Scale, which was used to test the structural design of the "Scissor-Tip-Separator" in terms of function, usability, and safety. The Adenosine Triphosphate surface test was also used to validate the "Scissor-Tip-Separator" cleanliness. Data were collected from August 2020 to November 2020, then analyzed via descriptive statistics.

Results

The "Scissor-Tip-Separator" met the cleaning validation criteria, and in 44 uses, the physical property remained the same. The scissor shank was discovered loose from the handle before it had been unlocked (0.2–0.4%) at the 45^th use. Based on participants' opinions, the overall instrument effectiveness was high in terms of function, usability, and safety.

Conclusion

The "Scissor-Tip-Separator" regulates scissor blade separation under sterilization guidelines; it prevents damage to cutting edges, thus ensuring patient safety. It protects against losses in a sterile field and can prevent hand injuries.

Controlling Infectious Risk in Transfusion: Assessing the Effectiveness of Skin Disinfection in Blood Donors

Bacterial infectious risk is a major problem in transfusion medicine. The type of micro-organisms isolated during bacterial contamination of blood products indicates that the donor’s skin is its main source. In this context, the primary measures to reduce this risk are: (a) optimal disinfection of the donor’s arm and (b) satellite bag diversion of the initial volume of blood collected. This work aimed to verify the effectiveness of skin disinfection of the blood donor’s venipuncture site. Two methodological approaches were used: (a) qualitative and quantitative microbiological testing of the skin at the collection site, before and post-disinfection; (b) qualitative microbiological testing of the first deviated blood. Pre-disinfection testing showed skin microbial load values between 3 and >200 CFU/plate. More than two-thirds of the isolates were Gram-positive bacteria (77.8%) of which 57.7% were staphylococci. Among Gram-negative bacteria, Pseudomonadaceae, Enterobacteriaceae, and Acinetobacter spp. were isolated from the blood donors (BDs). Post-disinfection, a 100% reduction in microbial load was observed in 84.4% of BDs. Microbiological testing of the first blood diverted sample revealed the presence of microbial flora in 1.9% samples; of the isolates, 83.3% were non-aureus staphylococci. This study highlights the importance of the correct application of skin disinfection procedures in order to ensure blood safety.

Cleanability of Metal Surface Finishes Found in Medical Devices and the Environment of Care

The surface finish of reusable medical devices often is a consideration during design, with attention paid to utility, aesthetics, and cost. To study the cleanability of metal surfaces of varying roughness and finish, soil made of bovine blood and egg yolk was placed on nickel alloy surface of varying average roughness (Ra) values (nominal values of 2-500 μin) and finishes (lapped, ground, milled, profiled, and shape turned). A commercially available wipe consisting of quaternary ammonium compound and less than 20% alcohol was applied for a total of eight wipe cycles to remove the soil. The wipe was applied in both horizontal and vertical directions. Evaluation methods for cleanliness include visual inspection and adenosine triphosphate (ATP) measurement. Rougher surfaces above nominal Ra of 250 were found to have higher ATP readings when wiped in both horizontal and vertical directions. In addition, different surface finishes have different cleanabilities despite similar nominal Ra. To ensure optimal cleaning, surfaces should be cleaned in multiple directions. In the future, similar studies will be coupled with efficacy studies and surfaces made with other materials will be investigated.

Simultaneous preconcentration and fluorescence detection of ATP by a hybrid nanocomposite of magnetic nanoparticles incorporated in mixed metal hydroxide

A new approach for increasing the sensitivity of adenosine triphosphate (ATP) detection was demonstrated. The assay was based on the synergetic function of a hybrid nanocomposite (MNPs@MMH) composed of magnetic nanoparticles (MNPs) incorporated in a mixed metal hydroxide (MMH). MNPs@MMH can be utilized as an efficient green extractant and peroxidase catalyst. The trace level of ATP in the sample solution was first extracted by the MNPs@MMH hybrid nanocomposite through the ion exchange properties of MMH and adsorbed on the surface of the MNPs@MMH. The concentration of ATP was related to the fluorescence intensity of 2,3-diaminophenazine (DAP) generated from peroxidase-like activity of the MNPs in the presence of H₂O₂ and o-phenylenediamine (OPD). In the presence of ATP, the active surface of the MNPs was diminished, and the amount of DAP generated was reduced. Thus, the concentration of ATP was related to the degree of fluorescence decrease compared to the fluorescence intensity of the system without ATP. Based on the proposed strategy, a highly sensitive assay for ATP was achieved. This assay exhibited good selectivity for detection of ATP over derivatives and other common anions. The proposed assay allowed the detection of ATP in a concentration range of 2.5-20 μM with a detection limit of 0.41 μM.

Multicenter comparative study of three "non-destructive" methods of detecting the cleanliness of the da Vinci surgical robotic instrument

BACKGROUND

The robotic instrument of the da Vinci surgical system determines the accuracy of robotic-assisted surgery, However, the most effective cleaning method of robotic equipment is a challenge for healthcare professionals. This study compared three da Vinci robot-assisted surgery manipulators to detect the effect of "non-destructive" testing of the cleaning effect by two different methods.

METHODS

The post-surgical cleaning of the da Vinci robotic instruments in the Sun Yat-sen University Cancer Center, The First Affiliated Hospital of Guangzhou Medical University and the Shenzhen Second People's Hospital was performed using two different processes from January 2019 to January 2020: manual joint automatic ultrasonic cleaning and automatic mechanical cleaning. The efficacy of visual estimation, the residual protein assay (quantitative) and adenosine triphosphate (ATP) biological biofluorescence detection of the cleanliness of the mechanical instrument's work (distal working end) surface and the shaft's inner chamber was compared. If the cleaning effect of any position on the surface or inner cavity of the manipulator did not qualify, the entire robotic instrument was judged as disqualified.

RESULTS

A total of 198 cases of da Vinci robotic instrument postoperative cleanliness data were collected. The qualifying rates of automatic ultrasonic cleaning were 96.97% by visual estimation, 93.94% by residual protein assay and 60.61% by ATP biological fluorescence detection. The respective rates for automatic mechanical cleaning were 100% by visual estimation, 90.91% by residual protein assay and 66.67% by ATP biological fluorescence detection.

CONCLUSIONS

The cleaning of the da Vinci robotic instrument detected by "non-destructive" residual protein assay or ATP biological fluorescence detection is more accurate than visual estimation.