Royal United Hospitals Bath NHS Foundation Trust has been able to undertake a full sterile services refurbishment project without disrupting services
In its six months of operation, a temporary sterile services facility, supplied by SSD Limited, to Royal United Hospitals Bath NHS Foundation Trust has enabled the busy department to continue working, processing an increased workload while achieving a KPI on breakdown callouts of just six hours and three minutes.
Like many other hospitals the refurbishment of sterile services at Bath had been postponed on a number of occasions while patient-facing schemes were given priority. This led to an increasing number of issues and cancellations as the equipment reached the end of its working life.
Now, as Soby Joseph, the trust’s sterile services and decontamination manger, explains: “The ongoing SSD centralisation project, which is now nearing completing, sees both endoscopy and instrument reprocessing located in one facility.”
Locating a temporary facility to reprocess the hospital’s flexible endoscopes was relatively straightforward. However, solving the instrument reprocessing conundrum proved to be a completely different matter.
“We considered several options; going elsewhere for reprocessing, phasing the refurbishment work, or locating a temporary facility,” says Soby.
Going offsite and using other hospitals’ facilities posed many issues: such as the logistics of time, the number of instruments being offsite, and the role of the decontamination staff during that period. The option of phasing what would be a major project while the department continued partial operation was something which the decontamination and capital project teams felt was too high a risk. So, the decision was made to source a temporary facility.
After asking other hospitals, IDSc (Institute of Decontamination Sciences) and equipment manufacturers, the only temporary solution which appeared to be available at the time was from a supplier in Belgium. However, at every stage of the negotiations there appeared to be issues with availability and what needed to be done.
“We struck lucky in a phone call to Olympus, who suggested we speak to Garth Rowbottom,” says Lee Williams, the trust’s technical projects manager. Garth, of SSD Limited, has many years of experience in decontamination and had already drawn up plans for a temporary SSD facility.
“We were right up against it,” explains Lee. “The clock was ticking. We had a programme of what was happening for sterile services. Garth came up with an idea of how we could do it. We worked with him through a number of phases to make the unit work. We always knew where it would be located – close to sterile services. The site presented its own issues: a pathway, bridge, fire regulations, a wall – all impinged on the size of the unit.”
Taking up the story, David Lockyer, deputy decontamination manager, says: “The trust supplied a specification to Garth, not for the equipment, just the throughput and facilities required. At the time we had four washer-disinfectors in the department, but one had broken down, so we were using three machines all the time. We decided that we definitely needed three for the temporary facility. It was up to SSD to select the manufacturer. We also needed a dedicated sink for manual washing, a Class 8 cleanroom for instrument packing and a despatch area.
“The initial plan was to have the temporary unit for eight weeks. We extended this to three months when speaking to Garth and eventually to the end of June to allow for completion of the centralised endoscope reprocessing and sterile services facility. The temporary unit was installed and commissioning finalised towards the end of December 2018, going live in January 2019.”
The two Portakabin buildings which the temporary facility comprises were built to SSD’s specification, ready for the installation of the equipment once the two units were positioned onsite.
The location presented its own issues, with the Portakabin buildings having to be carefully craned into position over a nearby bridge and precariously close to the second storey operating theatres. Everything was arranged in advance and all appropriate departments notified. The road was closed while the offloading and positioning was underway by the specialist team from Portakabin. The whole process was completed within two hours.
Once the units were in position the task of connecting them to the required services and fitting out with equipment could begin. One, smaller Portakabin building is the plantroom, housing the reverse osmosis (RO) water treatment equipment. The second, larger unit is the production area, housing the washer-disinfectors, clean room and despatch area.
Soby says: “The installation and commissioning went smoothly. The RO equipment is a duplex system, which Garth subcontracted to Envirogen. The washer-disinfectors Garth chose are DEKO D32 Excels supplied by Dekomed. The commissioning was by Audere Medical Services.
“Garth was also on hand to ensure everything went well. He arranged a deep clean of the facility and the validation documents on the machines and the clean room. These were approved by the trust’s APD, Owen Margetts, our AE(D), Mark Walker, and myself.
“After everyone had been trained, we began reprocessing instruments in the temporary unit in the second week of January. We were originally looking at having a larger production unit, but space and budget restricted us. Due to the compact size of the facility and the limited number of staff who can work in it at only one time, we started a night shift immediately to cope with the demand.”
Meeting increased workload
“We’ve 16 theatres on site and service a large number of outside clinics and GP surgeries,” explains Soby. “It’s a credit to the staff that we’ve been able to meet the increasing workload even in these relatively confined conditions.
“Our workload has increased, even during this difficult period. Working in the temporary unit, in January we processed 14,799 trays, in February 16,163, March 16,744, in May 17,597, and that’s only part of the production. When we include the offsite work, in May we processed a total of 24,297 trays.
“There’s a plus point with the number of trays that each of the three DEKO washer-disinfectors can accommodate in each cycle.”
Soby adds: “Garth’s always here if there is an issue. He responds straight away. It’s a great plus point. Even when he was on holiday in Spain, he responded immediately to a query I’d raised.”
David Lockyer explains: “So far we haven’t had much downtime. Maintenance gets full marks. We’ve had only one delay and one cancellation since the temporary unit went live in January. The maximum has been six hours only on one machine.
“After the cancellation, staff from the theatre involved came here – the theatre lead, a surgeon and the scrub team. They didn’t know we were working from a ‘shed’. They were impressed we had been able to keep working as well as we have. We didn’t know you were out of the department. Theatres are helping by sending daily lists, so we know what they need and prioritise.”
David says: “Comments we’ve had about the temporary unit include: ‘We thought it was a café’. Some theatre staff had an understanding of the refurbishment programme, but they have had so few issues they didn’t know what we were going through.
“The temporary unit is tight, but we’ve proved it’s doable It’s a big compliment to SSD and the staff here, who have been incredible. It shows how well the staff have worked in tight conditions.”
Beverley Parmenter, the trust’s quality manager – decontamination, adds: “We’ve been running a 24-hour service and it’s all gone well.”
With an engineering perspective, Owen Margetts, the trust’s senior estates officer – systems and authorised person – decontamination (APD), explains: “I was involved from the conception, when we were looking at where we were going, how we were going to move forward. Trying to find a temporary decontamination facility was like looking for unicorns.
“The initial validation process of the machines by Audere Medical Services was very thorough. The RO units and the washer-disinfectors have performed as I would have expected of quality machines. SSD were very helpful, very responsive to the few minor issues we had. I fully support Garth’s approach to continual monitoring to avoid any major faults.
“I think the projects gone very, very well. If all schemes ran as smoothly as this one, we wouldn’t have any issues. That’s full credit to Garth and his team.”
After the commissioning, SSD contracted engineer Sean Tovey, of Can West Services, to be responsible for the ongoing service and maintenance of the washer-disinfectors. Sean explains: “I try to be proactive, rather than reactive, to see if the machines are within calibration or drifting. If something is not looking right, it is replaced before it becomes an issue.
“Testing is dictated by documentation, so that’s every three months for the quarterly and then annually. I’m also contracted to fully assess the machines to ensure their integrity and reliability above and beyond the requirements of the documentation. The lack of issues shows that this is worthwhile. There were only a couple of minor issues when the temporary unit went live, which is what you might expect.”
Sean adds: “The performance of a machine is only as good as your last engineer. If you send in a good engineer, problems tend to disappear.”
Once commissioning was completed the facility was ready for a deep clean. When the chosen, relatively nearby contractor was unable to deliver the service, SSD’s Garth Rowbottom put in an emergency call to Mel Robson of SteriSystems. “Mel got me out of a tight spot,” says Garth. “With a colleague, Mel drove down from Scotland overnight, deep cleaned the facility and went back north the following day. He did a sterling job.”
The deep clean used the SteriAir mobile whole room decontamination unit, which is designed to provide medical professionals with a highly effective and adaptable means of infection prevention and control, using low dose hydrogen peroxide. The technology allows the disinfectant to be in contact, by displacement, with surfaces to be treated, including those which appear to be inaccessible. SteriAir is a dry solution, so all electronic equipment remains safe.
SteriAir is certified to the NF T72-281 (2014). As part of the decontamination cycle SteriSystems used its own high-level disinfectant that meets the latest EN Standards on contact times.
Garth says: “I’m qualified to operate a particle tester, and to undertake the drop plate and touch plate tests. Anderson Caledonia analysed the results and confirmed the clean room had achieved the required standard. The results were passed to the trust’s APD, Mark Walters, who approved it being a Class 8 clean room. In fact, the standard achieved for the production room of the temporary facility was better than the existing packing area of the hospital.”
Garth adds: “Initially, there were some water quality issues which required further testing. These were undertaken out of hours by 20/30 Labs.
“This was typical of suppliers throughout the programme. They constantly ‘pulled out all the stops’ to help the hospital achieve its tight timeframe.”
Describing his approach to meeting the trust’s requirements, Garth explains: “It was critical that the small, temporary facility kept going to serve the trust’s operating theatres. Because of the nature of the unit, the equipment didn’t need to be high tech, but it did need to be robust and be proven to be reliable. Based on that criteria we specified Envirogen for the RO, which were already installed across the hospitals site, and Franke’s DEKO washer-disinfectors-dryers, with their proven reliability.
“The final scheme was actually the sixth phase of the plans and the one that the trust team eventually agreed met their operating criteria and budget. As things progressed, we were asked to add in validation, supported maintenance etc.
“Once we got to stage of people saying yes, we looked for the appropriate contractors. It’s easier to negotiate a better rate with existing suppliers and contactors to the site than bring a new team.
“Envirogen are a well-established RO supplier to the trust. Likewise, JPS services, who handled the M&E under the direction of technical projects manager Lee Williams. While Audere Medical Services were already contracted for equipment service and commissioning.”
Garth adds: “I’m really proud of our Reported Fault to Repair KPI time. It stands at just six hours three minutes, which is incredibly fast. I know Soby is impressed with it.
“The unit’s performed so well that theatres didn’t know it was on site for a while. It’s met everything theatres had thrown at it. Which, I think, is a great compliment to the unit and the hard work of the decontamination team under very trying circumstances.”
Explaining the philosophy of SSD, Garth says: “Our aim is to make the difficult achievable and to get the job done without any fuss. As a company, we committed to the task. Our approach is always: whatever the problem, we will solve it, but you should give us a budget to work within. We’ll never charge more than the agreed price, so you may have to make compromises.
“From the start, we were very clear about who was doing what and who would put it right. In many instances when there were issues, our team at SSD put them right. It’s just part of what we do to keep things moving as smoothly as possible.”
‘Old School’ approach
“Maintenance followed an ‘Old School’ NHS approach,” says Garth. “We ran maintenance on the basis of weekly checks and monitored any deterioration in performance. For example, if a temperature fail was imminent, we had the replacement part on hand rather than wait for an issue to develop. Likewise, with drainage time. We had a new drain strainer on hand ready to put it in at the next water test. We analysed all the reports and looked for any potential deterioration in performance.
“The proof of the pudding’s in the eating. In the six months of the temporary facility being on site, the total number of breakdown callouts is just seven. It’s resulted in a response to breakdown call of just six hours and three minutes. In fact, we once had someone on site while Soby was on the phone calling to report the problem.
“With the trust using a night shift to meet demand, the unit’s been operating 24/7. The latest received call to an issue was at 23.40pm. Our engineer was on site the next morning, handing the machine back at 7.05am.”
Garth says: “‘Old School’ thinking was applied to the wash cycle too. You can either wash quick or wash well. I told the hospital: ‘I can give you a shorter cycle time, but you may then have to reprocess items which fail’. I adjusted the dwell time, which reduced the amount of kit failing to reprocess.
“We could have had a quicker throughput but not guaranteed they might need to reprocess. Given the volume that was being thrown at the department, that would have added to the problem. The mantra is: wash it well, not quick.”
Garth explains: “What we have learnt is that what the trust team thought couldn’t be done has been possible. In reality, anything can be achieved. You just need to know what you want.
“When you look at alternatives they were facing, such as taking equipment offsite, using a temporary facility is very cost-effective. Taking instruments offsite for reprocessing can require the purchase of more instruments to cover for time delays in transportation and reprocessing. It can also lead to the break-up of an established decontamination team. You really don’t want to lose a team of trained decontamination technicians while you do a refurbishment.”
News of the success of the temporary facility at Bath has certainly caused a stir. “We had nine different sites come to have a look,” says Garth. “Equipment manufacturers too. They were keen to look at how we had done it and particular to know what we charge.”
As a mark of their reliability, a number of Envirogen RO machines are already installed across the Bath hospital site, where they ensure the quality of the water supplied for key equipment. They were also chosen for the nearby temporary endoscopy unit and for both areas of the newly centralised sterile services and endoscope reprocessing unit.
Two Portakabin buildings, built to SSD’s structural specifications, house the temporary sterile services facility. A 7.28m2 Portakabin building, with a reinforced floor, forms the plant room, housing a duplex EndoTherm Duo RO system from UK manufacturers Envirogen, to feed the washer-disinfectors.
The EndoTherm Duo model houses two separate RO units within the same cabinet. Having two RO units gives 100 per cent resilience, allowing for scheduled maintenance/service when required without the loss of purified water.
The EndoTherm Duo has its own ring main feeding RO water to all three washer-disinfectors. It was also supplied with two duplex water softeners, one to feed the duplex EndoTherm Duo RO system and one to feed the cold softened process water to the washer-disinfectors.
Allan Wigglesworth, healthcare market manager for Envirogen, says: “We have a long-standing relationship with Bath and were very pleased that SSD chose our equipment for the scheme. It’s the first EndoTherm Duo duplex install for a temporary instrument reprocessing facility, but yet again it’s delivered 100 per cent reliability.”
The adjacent production unit is a 10m by 35.80m2 Portakabin building with a reinforced floor and air conditioning units.
The receiving area has twin bowl sink for items which require manual washing. Instruments for processing are placed on 18 Din trays and loaded into one of the three, compact, high capacity Franke DEKO D32 Excel pass-through washer-disinfector-dryers, supplied by Dekomed.
The DEKO D32s Excels are designed and constructed to exceed the standard performance and design requirements stated in ISO/DIS 15883-1 Washer-disinfectors – Parts 1 and 2: and IEC 61010-2-45. They guarantee process results throughout with a Class C independent, full process verification recording system. Water pressure for washing is via a high-powered circulation pump. Pipework and the number of loading shelves fitted with rotating spray arms are calculated to have the maximum soil removal efficacy. Washing spray patterns delivered through five rotating spray arms are purpose-designed racks to guarantee contact with all surfaces and crevices of instruments with the most intricate design.
The machines offer a wide selection of disinfection temperatures and cycle times to secure the microbial killing impact. The unit’s touch screen technology displays a range of information throughout the cycle, together with service actions and routine checks. As is the case at Bath, cycles can be altered to meet almost any special requirement.
Once the cycle is complete, the pass-through machine is unloaded into the Class 8 cleanroom, where the instruments are checked and wrapped ready for despatch to the sterilisers.
Steve Townsend, projects manager at Dekomed, says: “We liaised closely with Garth and the SSD team throughout the installation, commission and operation of the temporary reprocessing unit to ensure the machines delivered a first-class service.”
With the new centralised sterile services and endoscope reprocessing department now operational, the temporary sterile services unit has been decommissioned. It delivered over six months of virtually faultless operation, which enabled the trust to meet the increased demands placed upon it. Indeed, it was so successful that theatre teams hardly realised what was happening.
What initially looked like ‘Mission Impossible’ for Royal United Hospitals Bath NHS Foundation Trust proved to be ‘Mission Achievable’.