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Boiling: The Answer to High-Level Disinfecting of Surgical Instrumentation in a Village of a Third World Country

Sharon Greene-Golden, CRCST

Introduction

A Bangladeshi-American Physicians’ cry was for a Sterilization Technician to travel to his birth country to provide a needed service to the Bangladeshi people.

A team consisting of an Anesthesia provider, Operating Room Nurses, Surgical and Sterilization Technicians was a prerequisite for the future surgical mission to his homeland, Bangladesh. A. Sterilization technician traveling to a Third World country? The very thought of assisting and teaching others peeked my interest. I thought to myself, sterilizing instruments won’t be an issue; it’s as simple as having a sterilizer, decontamination area, water and instruments. This is going to be walk in the park. I made the phone call the Bangladeshi-American Physician was waiting for and told him, I AM IN!

In 1998, this Sterilization Technician became part of a surgical mission to the country of Bangladesh. Time was spent online researching the country in an effort to prepare for the conditions and challenges that would be faced on this journey. The sixth edition of the Central Service manual on hand the parameters of sterilization memorized this technician was ready to work. Never in my wildest dreams did I ever think of working in villages while using boiling pots for the processing of instrumentation. Questions flooded my mind, how long do you boil, are the processed instruments sterile? Online research would answer these questions. Research allowed me to have the official parameters for boiling surgical instruments. Boiling would be the method for processing instruments in the village. An important parameter learned was, boiled instruments are not sterile; they are high-level disinfected (HLD). So, the thought that sterilizing instruments would be a walk in the park had changed to a mountain climbing expedition. Future surgical missions would start and end in the different villages of Bangladesh with the boiling of instrumentation for surgery.

Experiment

It’s November 2006 and the Project Bangladesh team consisting of one physician, a nurse anesthetist, an operating room nurse, two surgical technicians and one sterile processing technician prepare for a four hour journey to a village. We arrive at a three story concrete complex in various stages of completion which houses the hospital. The surgical area is located on the second floor. We walk into a small office where we are to meet and access our patients. In the corner stands a four foot tall drum (pressure cooker) sterilizer. The challenge would be processing instruments for surgical cases in this space. We set up our services in the small two room operating theater. I had access to one drum (pressure cooker) sterilizer and a boiling pot. I pondered how to utilize a boiling pot for the high-level disinfection process. Upon entering the operating suite, I first learned that the drum sterilizer was not available for use until in the evening. They were more than happy to provide me with a boiling pot. As studies about boiling flashed through my mind, I asked where the decontamination area was located. I found out that we had one community sink; first, you scrub for surgery then it became the decontamination area. This sink was located in front of the community bathroom. My main concern was being able to provide a quality product for our patients. I had to be able to provide instruments that were clean and ready to be disinfected by boiling. I set-up a portable decontamination station consisting of two basins on a ring stand beside the community sink. I also had cleaning brushes, a cleaning agent, syringes for flushing, and towels for drying as needed. An important goal in this process was to have clean instruments. Once the instruments were clean, I then selected the instruments needed for the surgical procedure and placed them on a stringer. Next, I placed the stringer with instruments in the boiling pot and waited for a gentle rolling boil. Once boiling, I started timing. At approximately twenty minutes, I took the Cheatle forceps and removed the instruments from the pot. These instruments were then placed on the sterile field for the surgical case that was to proceed immediately. I took time to explain to the technicians from Bangladesh what my procedures were and how we would effectively use this method all day and how I planned to implement these methods for the duration of my tenure there. This practice was performed for sixty surgical cases over an eight day period.

Individuals working in a village encounter various challenges when attempting to process instruments. Limited resources; such as water, sinks and electricity, are problematic when processing instruments. The cleaning process is paramount to high-level disinfection. Boiling provides disinfection of instruments. The technician must boil the instruments at the correct temperature and for the correct duration. If processed correctly, instruments that are cleaned are high-leveled disinfected (HLD) and ready for use in any surgical case.

In the 19th century, surgery was a dangerous process. If a patient was scheduled to have a simple surgery, the risk of contracting an infection was astronomical. Surgery was not performed under aseptic conditions. Studies show that the operating room, the surgeon’s hands, and the surgical instruments were laden with microbes. These microbes caused high levels of infection and mortality (Todar, 2008).

Surgeons in mid-1800 often wore their street clothes while operating without washing their hands. They frequently used ordinary sewing thread to suture wounds, and stuck needles in the lapels of their frock coats in between patients. Surgical dressings were often made up of surplus cotton or jute straight from the floors of cotton mills (Todar, 2008).

It was at this time that French scientist, Louis Pasteur, demonstrated that invisible microbes caused disease. Dr. Pasteur’s studies helped to influence an English surgeon named Joseph Lister. Lister was credited with founding modern antiseptic procedures for surgery. His plan included the spraying of operating rooms with a solution of carbolic acid (phenol) before every case. It was then noted that the survival rates for surgery did increase due to Lister’s methods. As studies continued over time, scientists learned that chemical agents would either kill or prevent the growth of microorganisms. At this time the study of microbiology took a higher priority in the surgical outcome of patients (Todar, 2008). In microbiology, sterilization refers to the complete destruction or elimination of all viable organisms in or on a substance being “germ-free”.

During this time in history, boiling was widely considered a great form of sterilization. Boiling water was our most powerful germicide via the rapidity of its action being excelled only by flame contact. It is, however, more certain than the latter, because every part of the article to be sterilized may be brought into direct and simultaneous contact with an intense and uniform degree of heat. This method will destroy, with certainty, all forms of pathogenic micro-organisms and their spores within five minutes; thus, it forms an ideal process. Water can be quickly heated to the boiling point, making it time efficient. The boiling mass possesses a really uniform temperature throughout the system it can be depended upon for thorough work. It requires no extensive appliances, chemicals or time loss. It is economical. As time evolved and research continued, we learned that items boiled were not sterile but were to be considered high-level disinfected (Todar, 2008).

The world consensus confirmed sterilization the safest and most effective method for the processing of instruments; often, sterilization equipment is either unavailable or not suitable (Rutala, 1996). In these cases, high-level disinfection is the only acceptable alternative. Research has proven that boiling instruments in water for twenty minutes will kill all vegetative forms of bacteria, viruses including hepatitis B, hepatitis C and Human Immunodeficiency Virus (HBV, HCV, and HIV), yeasts, fungi and tuberculosis. Boiling will not kill all endospores reliably. To this end, we know that high-level disinfection, not sterilization, can be achieved by boiling water.

Cleaning, an essential beginning to ensure high-level disinfection can subsequently be achieved. Cleaning is a process which physically removes contamination but does not necessarily destroy micro-organisms. Microbes are much more easily killed if instruments are clean. It is also important to have a good cleaning agent that effectively helps to destroy bacteria (Central Service Technical Manual, 2007).

One will show up in a village to find out they have only one drum autoclave that is used only once a day due to electrical constraints. The only method you will have to process the instruments for surgical cases is boiling. When correctly using the process for boiling instruments, the technician can effectively prepare for the surgical cases. It is important that the technician have a guide as to the process for boiling instruments. Listed are the complete and official seven steps you need to follow in order to achieve high-level disinfection by boiling.

Methods

Step: 1 – Decontaminate and clean all instruments and other items to be high-level disinfected.

Step: 2 – If possible, completely immerse items in water. Adjust the water level so that there is at least 2.5 cm (1 inch) of water above the instruments. In addition, make sure all bowls and containers to be boiled are full of water.

Step: 3 – Close lid over pan and bring water to a gentle, rolling boil. Boiling too vigorously wastes fuel, rapidly evaporates the water and may damage delicate or sharp instruments.

Step: 4 – Note when rolling boil begins, then start timing.

Step: 5 – Boil all items for twenty minutes

Step: 6 – After boiling for twenty minutes remove objects with previously high level disinfected forceps. Never leave boiled instruments in water that has stopped boiling. As the water cools and steam condenses, air and dust particles are drawn down into the container and may contaminate the instruments (Perkins 1983). The long-handled forceps used to remove the instruments are called Cheatle’s. The Cheatle forceps are boiled first and then placed in a container with cresol (“Lysol”) up to their handles. This is done daily (Tietjen LG, W Cronin and N McIntosh, 1992).

Step: 7 – Use instruments and other items immediately, or with high-level disinfected forceps or gloves, place objects in a high-level disinfected container with a tight fitting cover. Once the instruments are dry, if any pooled water remains in the bottom of the container, remove the dry items and place them in another high-level disinfected container that is dry and can be tightly covered (Tietjen LG, W Cronin and N McIntosh, 1992).

Analysis and Discussion

Studies and personal experiences show that whenever boiling is used as the method for high-level disinfecting, lime deposits may form on the metal instruments. This scale formation, caused by lime salts in the water, is difficult to avoid.

By following these steps, however, the problem of lime deposits can be minimized:

Step: 1 – Boil water for ten minutes at the beginning of each day before use. This process precipitates much of the lime salt in the water on to the walls of the boiling pot before instruments are added.

Step: 2 – Use the same water throughout the day, adding only enough to keep the surface at least one inch above the instruments to be high-level disinfected. Frequent draining and replacing the water, and boiling too vigorously, increase the risk of lime deposits on instruments.

Step: 3 – Drain and clean the boiler or pot at the end of each day to remove lime deposits (Tietjen LG, W Cronin and N McIntosh, 1992).

Illustrations

These are illustrations of different size boiling pots, non-boiling and rolling boiling, lime deposits, drum sterilizers and placement of instruments onto the sterile field. These pictures bring the steps described in this paper to life from the six different mission trips.

Conclusion

In today’s society, people believe in the thought that “We are our brothers’ keepers”. In this world, it is an accepted practice that as members of this society, we give back from our abundance. As we become “Mission Minded Sterilization Technicians”, it is imperative that we function normally with limited resources as we work in other countries. In Bangladesh, hospitals have units labeled “dirty wards” for patients who have contracted all types of infections. Approximately 17 percent of these infections are attributed to some type of surgical procedure. The magnitude of surgical site infection is a profound problem. It is critical that sterile processing Technicians traveling to serve in Third World countries be prepared to adapt professionally with knowledge in all settings of sterilization. The data has shown in this paper that high-level disinfection by boiling is the answer to processing instrumentation in Third World Country villages when formal sterilization methods are restricted.

References

AORN Standards and Recommended Practices (Denver: Association of Operating Room Nurses, Inc.2002.

Association for the Advancement of Medical Instrumentation, Good Hospital Practice: Steam Sterilization and Sterility Assurance, ANSI/AAMI (Arlington VA); Association for the Advancement of Medical Instrumentation, 1944.

Block SS (ed). 1991. Disinfection, Sterilization and Preservation, 4th ed. Lea & Febiger:Philadelphia

Central Service Technical Manual, 7th Edition, Jack Ninemeier. PhD, Editor, International Association of Healthcare Central Service Materiel Management (2007)

Favero MS. 1985. Sterilization, disinfection, and antisepsis in the hospital, in Manual of Clinical Microbiology, 4th ed. Lennette EH et al (eds). American Society for Microbiology: Washington, DC, pp 120-137.

Fortunato-Phillips, N. Berry & Kohn’s Operating Room Technique, 10th ed. St. Louis:Mosby, 2003.

Gardner, J. F., Peel, M. H. Introduction to Sterilization and Disinfection. New York City:Churchill Livingstone, 1996.

IPAS 1993. Boiling IPAS Cannulas to Achieve High-Level Disinfection. IPAS: Carrboro, NC, Scientific Report Summary.

Perkins JJ. 1983. Principles and Methods of Sterilization in Health Sciences, 2nd ed. Charles C. Thomas Publisher Ltd.: Springfield, IL.

Rutala WA. 1993. Disinfection, sterilization and waste disposal, in Prevention and Control of Nosocomial Infections, 2nd ed. Wenzel RP (ed). Williams & Wilkins:Baltimore, MD, pp 460-495.

Rutala WA. 1996. APIC guidelines for selection and use of disinfections. American Journal of Infection Control, 24(4): 313-342.

Tietjen LG, W Cronin and N McIntosh. 1992. High-level disinfection, in Infection Prevention Guidelines for Family Planning Programs. Essential Medical Information Systems, Inc.: Durant, OK, pp 74-84.

Tietjen LG and N McIntosh. 1989. Infection prevention in family planning facilities. Outlook 7: 2-8.

Todar, Kenneth. 2008 University of Wisconsin-Madison Department of Bacteriology. Todar’s Online Textbook of Bacteriology www.testbookofbacteriology.net/control.html

World Health Organization (WHO). 1989. Guidelines on Sterilization and High-Level Disinfection Methods Effective Against Human Immunodeficiency Virus (HIV).WHO: Geneva. AIDS Series 2.