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Sterilization of instruments in general practice: what does it entail?
Public Health (1997) 111 115417 @The Society of Public H&h, 1997
Sterilization
of
instruments in general Practice: what does it entail?
KW Allen’, H Humphreys* and RF Sims-Williams3 ‘Consultant in Communicable Disease Control, Barnsley and Doncaster Health Authorities; 2Senior Lecturer and Honorary Consultant, Division of Microbiology and Public Health Laboratory university Hospital, Nottingham; and 3,!?terile services Manager, The King’s Mill Centre for Health Care services, SUtton-in-Ash$eld, Nottinghamshire There is increasing interest amongst general practitioners in carrying out minor surgicalproceduresbut it is unclear what resourcesare available for this. We decided to assessthe level of knowledge of sterilization and the use of benchtop sterilisersin general practice by circulating a postal questionnaire to the 883 general practices in the Trent Regional Health Authority. The responserate was 49%. Mmor surgrcalprocedureswere performed in 86% of practices but less than half of respondents understood what was meant by sterilization. 28% consideredthat the goor of the surgeryshould be disinfected or sterilisedand 13% believed that immersion in 2% glutaraldehydefor 10 nun consmuted sterilization. 93% had a benchtop steriliser,only a quarter kept a log book, and approximately a third had it servicedat intervals of one year or longer. Less than 50% understood the correct position in which a bowl or kidney dish should be placed and 41% had used or had accessto a local sterile servicesdepartment. The conceptof sterilization is not clearly understood and the use of benchtop sterilisersin Trent is suboptimal. On-going education of staff in primary care is required and consideration should be given to a system of accreditation. Keywords: sterilization; disinfection; decontamination; general practice; minor surgery
Introduction There is increasing activity amongst general practitioners (GPs) in carrying out minor surgical procedures. GPs claimed reimbursement in four English family health
services authorities for 600 minor surgical procedures between June 1990 and June 1991, an increase of 41%.’ In an effort to reduce the load on hospital practice, the NHS Management Executive has encouraged even more minor surgery in primary care.’ This has led to calls for improved
training of GPs in surgical procedures such as removal of skin lesions and cryotherapy.3 A Safety Action Bulletin issued in April 1992 states that each transportable steam steriliser should have a log book, routine tests should be carried out, readings on the sterilising gauges taken regularly and details on the holding period noted with quarterly or annual tests carried out by properly qualified ~taff.~ These developments have not apparently been accompanied, however, by appropriate education on what facilities and resources are required for sterilization of surgical instruments. The Trent Regional Working Party on Sterilisation and Disinfection (TRWPSD), a multi-disciplinary group of health care personnel which included microbiologists, engineers, sterile service managers and public health physi@ns advised on all aspects of sterilization in hospitals and in the community up to the recent reorganization of the regions. The increasing emphasis on minor surgery in general practice and concern over whether benchtop sterilisers were being used correctly prompted us to carry out a survey of sterilization facilities available in primary care throughout the Trent region. This report outlines the major findings from this survey, which was carried out by questionnaire. Correspondence:Dr H Humphreys,Division of Microbiology and PublicHealth Laboratory, UniversityHospital, Queen’sMedical Centre,Nottingham, NG7 2UH. Accepted6 December1996
Methods
The questionnaire was initially piloted in one of the smaller districts of the Trent Regional Authority (pre-1994 boundaries), modified and then administered with the cooperation of the eight Family Health Services Authorities (FHSAs) in late 1993. The accompanying covering letter specifically requested the questionnaire be completed by the individual operating any sterilizer used in the practice rather than by the GP exclusively who might be less familiar with its operation. Replies were returned in confidence. The questionnaire sought information on the surgical procedures carried out in the practice, facilities available for sterilization or disinfection, for example bench top steriliser. We also attempted to assess the respondents understanding of the concepts of sterilization and disinfection and the circumstances in which cleaning, disinfection or sterilization were the most appropriate. We defined sterilization as a process used to render an object free from viable microorganisms, including bacterial spores and viruses. We defined disinfection as a process used to reduce the number of viable microorganisms but which may not inactivate
some viruses or bacterial
spores.
Cleaning, an essential pre-requisite for disinfection and sterilization, was defined by the authors as a process which physically removes contamination and hence reduces the microbial load but does not necessarily render microorganisms non-viable. Responses to the questions were collated and analyzed using the Epi-info computer database programme.
Results Questionnaires were circulated to all 883 practices in Trent and 437 were returned after the initial circulation and a subsequent reminder to non-responders, a final response rate of 49%. Sixty-nine per cent of practices were based in private surgeries and the majority of practices had 300&
116
GP sterilization of instruments KWAllen et al
Table 1 Surgicalprocedurestaking place in the practicesof the 437 responders.
No (%)
Procedure Minor surgery Urinary catheterization Syringing
374 (86) 92 (21) 432 (99)
ears
Dressings/treatmentswith instruments Family planning (for example insertion of coils) Cervical smears All of the above
414 (95) 373 (85) 435 (99) 83 (19)
8000 patients. Minor surgical procedures were carried out in 374 (86%) practices and approximately 20% carried out a comprehensive range of activities (Table 1). Eighty-three (19%) respondents understood what was meant by the term ‘sterilization’; the term ‘disinfection’ was understood by 188 (46%). The relative indications for sterilization, disinfection and cleaning were assessed by asking the respondents to indicate what was appropriate in different situations (Table 2). One hundred and twenty-two (28%) replied that the surgical floor should be disinfected or sterilized and over 90% considered that a vaginal speculum should be sterilized. Two hundred and thirty-one (53%) considered that disinfection was appropriate for ear syringes. Four hundred and two (90%) correctly identified steam under pressure at 134°C as an appropriate method of sterilization. Fifty-seven (13%) believed that immersion in 2% glutaraldehyde, for example Cidex for 10min constituted sterilization and 3 1 (7%) considered that immersion in hot water at 70-100°C for 1Omin was adequate to sterilize instruments or equipment and by implication could be considered safe and appropriate practice. Four hundred and seven (94%) of those practices responding had a benchtop sterilizer; 55% had purchased it within the last 5 y, 3% over 10 y ago. The most common type (65%) was SES/Eschmann (Little Sister autoclave) but 11% indicated incorrectly that a hot water boiler fell into this category. The sterilizer was covered by third party liability insurance in 220 (49%) of cases and there was a written procedure in place for its use in 246 (63%) practices. Cleaning and maintenance schedules varied considerably with 162 (37%) carrying these out on a weekly basis but 152 (35%) indicated that these were done less frequently than this or only occasionally. Ninety-one (33%) respondents indicated that the sterilizer was serviced by a qualified technician only when there was a problem
and 30% indicated this was done at intervals of one year or longer. When asked to indicate the position in which a bowl or kidney dish should be placed in a benchtop sterilizer, 187 (43%) replied incorrectly, ie upside down, and only 48 (11%) could provide reasons why the correct position was important, for example to allow displacement of air and steam penetration. One hundred and eight-one (42%) had access locally to a sterile services department and 123 (60%) of the remainder were interested in availing of such facilities.
Discussion
The results of this survey indicate the wide range of minor surgical procedures already being carried out in general practice in the region. There is some confusion, however, over the need for maintenance and the correct use of benchtop sterilizers. This was subsequently confhmed during half day workshops which were conducted throughout the region and which were well attended by GPs and practice nurses. These workshops enhanced the considerable confusion and apprehension that exists over responsibilities in this area. Only 69 of 111 practices had adequate facilities for minor surgery in a survey carried out in Leeds but they considered ‘sterilization by boiling in a custom built appliance’ the minimum acceptable.s There is no guarantee, however, that such conditions will result in the removal of all microbes including bacterial spores, as the temperatures achieved and the exposure time will vary. A review of 24 practices, concentrating on infection control practice, revealed inappropriate use of chemical disinfectants and a lack of detailed knowledge of autoclave test procedures and maintenance.6 Another study of 600 GPs conducted by the British Medical Association (BMA) did not reveal a significant association between the size of the practice and having an autoclave but 22% of high risk instruments were inadequately decontaminated, largely due to the inappropriate use of hot water disinfectors’ but the maintenance of benchtop sterilizers was not, however, covered by this particular study. A subsequent Code of Practice drawn up by the BMA, which advised dividing up procedures and the use of instruments into high, medium and low risk, recommended that autoclaves should be serviced every 3-6 months, routing tests conducted weekly and the results recorded.* A further study of six general practice surgeries, which assessed the understanding of the principle of decontami-
Table 2 Replies on the most appropriate method of decontamination for the surgery
floor and a variety of instruments and articles from the 437 responders Itema Surgeryfloor (C) Thermometer (D) W-he
@I
Vaginal speculum (S) Auroscope ear piece (D) Scalpel (S) Metal forceps (S) Ear syringe (S)
Ring pessary(S) NA: not answered. ‘Letter in parenthesis
indicates
Sterilization
Disinfection
Cleaning
NA
1%
27% 84% 4.5% 3% 62% 2%
62% 5% 0.5% 0% 5% 0%
10%
6% 81% 93% 27% 93% 96% 26% 57% the recommended
1% 53% 29% option,
C cleaning,
0% 15% 6% D disinfection,
5% 14% 4% 6% 5% 3% 6% 8% S sterilization.
GP sterilization KW Allen et al
nation, has also revealed a lack of understanding of the importance of using sterile instruments for carrying out all invasive procedures and revealed deficiencies in the correct use, monitoring, maintenance and storage of decontaminated equipment and antiseptics.g This was reflected in our study in which over half of respondents considered disinfection adequate for ear syringes, instruments which may come in contact with blood. Confusion over instrument sterilization is not confined to the UK; a recent evaluation of dental instrument and device sterilization in the USA revealed that only 68% of items, for which sterilization was considered essential, were sterilized.” Whilst the great majority of respondents in our study indicated that steam under pressure was appropriate for sterilization, approximately one in eight considered that immersion in 2% glutaraldehdye for 10 min was also suitable. Short exposure to glutaraldehyde will kill vegetative bacteria and inactivate most viruses but a 10 min exposure may only kill small numbers of Mycobacterium tuberculosis and a longer exposure, 2-3 h, is required to kill other mycobacteria.” The use of aldehydes in general practice should be discouraged because these compounds are potentially toxic, may sensitize some individuals and appropriate facilities including ventilation are required for their use.i2 Less than half the respondents to our questionnaire were sure of the reasons why wrapped instruments can not be adequately sterilised in benchtop sterilisers. Bags or wrapping should not be used in any autoclave steriliser unless air can be driven out,i3 and this also means that placing bowls or kidney dishes in the upside down position is incorrect. Commercially available benchtop sterilizers used in general practice do not drive air out and a recent Safety Action Bulletin has highlighted this.14 In those practices where minor surgical procedures are performed less often or where it is decided not to have on-site sterilization facilities, the use of a Sterile Services Department (SSD) is an appropriate alternative. SSDs can usually provide sterile instruments for minor surgical procedures, dressings, sets for family planning and even purchase and maintain instruments on behalf of the practice. This will obviate the need for a benchtop sterilizer which is a more complex piece of equipment than is often recognised. During workshops conducted by the authors which followed the survey, there was considerable dismay expressed at the requirement for the initial detailed commissioning and regular monitoring of sterilizers in addition to the keeping of log books, but nonetheless a willingness to improve standards. Furthermore, the extent of the responsibility of the user and the need for insurance is not .always fully appreciated. The response rate from our survey was less than 50% and it is likely that those responding recognised a need for further education; the majority of those circulated, however, may not consider this issue a priority. Individuals managerially responsible for sterilization in hospital or on ,other premises need to be familiar with health and safety aspects, need to ensure that
117
of instruments
personnel at all levels have a general knowledge of the principles involved and need to have a designated competent person for regular inspections.‘5 We believe that greater attention needs to be focused on surgical facilities in general practice and there is a need for ongoing education in this area. Ultimately, higher standards might best be achieved in the form of accreditation SPecifiCally for sterilizing procedures, at regional or national level, after a process of training and inspection with Particular emphasis placed on the purchase, care and maintenance of bench top sterilizers.
Acknowledgements We wish to thank the TRWPSD for their support, J Buckle for help in collating the results and finally, those who returned questionnaires. We are grateful to Mr RA Needham for his assistance in conducting the workshops.
References 1 LOWE A et al. Minor surgery by general practitioners under the 1990 contract: effects on hospital workload. BMJ 1993; 307: 413-417. 2 GP Fund-Holding Practices: The Provision of Secondary Cure. Health Services Guidelines. NHS Management Executive 1993; HSG (93) 14. 3 Kneebone RL. Training general practitioners in minor surgery. Br J Gen Pratt 1994; 44: 103-104. 4 Transportable Steam Sterilisers: Maintenance, Inspection and Insurance. Safety Action Bulletin: London, 1992; No. 82 (92) 27. Zolte N, Hoult G. Adequacy of general practitioners’ premises for minor surgery. BMJ 1991; 302: 941-942. Hoffman PN et al. Control of infection in general practice: a survey and recommendations. BMJ 1988; 297: 34-36. Morgan DR, Lamont TJ, Dawson JD, Booth C. Decontamination of instruments and control of cross infection in general practice. BMJ 1990; 300: 1379-1380. 8 A Code of Practice for Sterilisation of Instruments and Control of Cross Infection. British Medical Association: London, 1993. 9 Rogers J. Sterilisation in GP surgeries. Nurs Times 1989; 85: 65-69. 10 Gurevich I, Dubin R, Cunha BA. Dental instrument and device sterilization and disinfection practices. JHosp Infect 1996; 32: 295-304. GAJ, Babb JP, Bradley CR. ‘Sterilization’ of 11 Ayliffe arthroscopes and laparoscopes. J Hosp Infect 1992; 22: 265 269. 12 Babb JR. Chemical disinfection and COSHH: safe and effective work practices. J Steriles Services Management 1990; 1 (July/August, No. 10): 9-12. 13 Wood PR, Martin MV. A study of the use of autoclave bags in non-vacuum autoclaves. J Dent 1989; 17: 148-149. 14 ‘Instrument and Utensil’ Steam Sterilisers: Misuse. Safety Action Bulletin: London, 1989; NO. 52 (89) 73. 15 Sterilisation. Part 1. Management Policy. Health Technical Memorandum 2010. NHS Estates: London, 1994.
Sterilization
of
instruments in general Practice: what does it entail?
KW Allen’, H Humphreys* and RF Sims-Williams3 ‘Consultant in Communicable Disease Control, Barnsley and Doncaster Health Authorities; 2Senior Lecturer and Honorary Consultant, Division of Microbiology and Public Health Laboratory university Hospital, Nottingham; and 3,!?terile services Manager, The King’s Mill Centre for Health Care services, SUtton-in-Ash$eld, Nottinghamshire There is increasing interest amongst general practitioners in carrying out minor surgicalproceduresbut it is unclear what resourcesare available for this. We decided to assessthe level of knowledge of sterilization and the use of benchtop sterilisersin general practice by circulating a postal questionnaire to the 883 general practices in the Trent Regional Health Authority. The responserate was 49%. Mmor surgrcalprocedureswere performed in 86% of practices but less than half of respondents understood what was meant by sterilization. 28% consideredthat the goor of the surgeryshould be disinfected or sterilisedand 13% believed that immersion in 2% glutaraldehydefor 10 nun consmuted sterilization. 93% had a benchtop steriliser,only a quarter kept a log book, and approximately a third had it servicedat intervals of one year or longer. Less than 50% understood the correct position in which a bowl or kidney dish should be placed and 41% had used or had accessto a local sterile servicesdepartment. The conceptof sterilization is not clearly understood and the use of benchtop sterilisersin Trent is suboptimal. On-going education of staff in primary care is required and consideration should be given to a system of accreditation. Keywords: sterilization; disinfection; decontamination; general practice; minor surgery
Introduction There is increasing activity amongst general practitioners (GPs) in carrying out minor surgical procedures. GPs claimed reimbursement in four English family health
services authorities for 600 minor surgical procedures between June 1990 and June 1991, an increase of 41%.’ In an effort to reduce the load on hospital practice, the NHS Management Executive has encouraged even more minor surgery in primary care.’ This has led to calls for improved
training of GPs in surgical procedures such as removal of skin lesions and cryotherapy.3 A Safety Action Bulletin issued in April 1992 states that each transportable steam steriliser should have a log book, routine tests should be carried out, readings on the sterilising gauges taken regularly and details on the holding period noted with quarterly or annual tests carried out by properly qualified ~taff.~ These developments have not apparently been accompanied, however, by appropriate education on what facilities and resources are required for sterilization of surgical instruments. The Trent Regional Working Party on Sterilisation and Disinfection (TRWPSD), a multi-disciplinary group of health care personnel which included microbiologists, engineers, sterile service managers and public health physi@ns advised on all aspects of sterilization in hospitals and in the community up to the recent reorganization of the regions. The increasing emphasis on minor surgery in general practice and concern over whether benchtop sterilisers were being used correctly prompted us to carry out a survey of sterilization facilities available in primary care throughout the Trent region. This report outlines the major findings from this survey, which was carried out by questionnaire. Correspondence:Dr H Humphreys,Division of Microbiology and PublicHealth Laboratory, UniversityHospital, Queen’sMedical Centre,Nottingham, NG7 2UH. Accepted6 December1996
Methods
The questionnaire was initially piloted in one of the smaller districts of the Trent Regional Authority (pre-1994 boundaries), modified and then administered with the cooperation of the eight Family Health Services Authorities (FHSAs) in late 1993. The accompanying covering letter specifically requested the questionnaire be completed by the individual operating any sterilizer used in the practice rather than by the GP exclusively who might be less familiar with its operation. Replies were returned in confidence. The questionnaire sought information on the surgical procedures carried out in the practice, facilities available for sterilization or disinfection, for example bench top steriliser. We also attempted to assess the respondents understanding of the concepts of sterilization and disinfection and the circumstances in which cleaning, disinfection or sterilization were the most appropriate. We defined sterilization as a process used to render an object free from viable microorganisms, including bacterial spores and viruses. We defined disinfection as a process used to reduce the number of viable microorganisms but which may not inactivate
some viruses or bacterial
spores.
Cleaning, an essential pre-requisite for disinfection and sterilization, was defined by the authors as a process which physically removes contamination and hence reduces the microbial load but does not necessarily render microorganisms non-viable. Responses to the questions were collated and analyzed using the Epi-info computer database programme.
Results Questionnaires were circulated to all 883 practices in Trent and 437 were returned after the initial circulation and a subsequent reminder to non-responders, a final response rate of 49%. Sixty-nine per cent of practices were based in private surgeries and the majority of practices had 300&
116
GP sterilization of instruments KWAllen et al
Table 1 Surgicalprocedurestaking place in the practicesof the 437 responders.
No (%)
Procedure Minor surgery Urinary catheterization Syringing
374 (86) 92 (21) 432 (99)
ears
Dressings/treatmentswith instruments Family planning (for example insertion of coils) Cervical smears All of the above
414 (95) 373 (85) 435 (99) 83 (19)
8000 patients. Minor surgical procedures were carried out in 374 (86%) practices and approximately 20% carried out a comprehensive range of activities (Table 1). Eighty-three (19%) respondents understood what was meant by the term ‘sterilization’; the term ‘disinfection’ was understood by 188 (46%). The relative indications for sterilization, disinfection and cleaning were assessed by asking the respondents to indicate what was appropriate in different situations (Table 2). One hundred and twenty-two (28%) replied that the surgical floor should be disinfected or sterilized and over 90% considered that a vaginal speculum should be sterilized. Two hundred and thirty-one (53%) considered that disinfection was appropriate for ear syringes. Four hundred and two (90%) correctly identified steam under pressure at 134°C as an appropriate method of sterilization. Fifty-seven (13%) believed that immersion in 2% glutaraldehyde, for example Cidex for 10min constituted sterilization and 3 1 (7%) considered that immersion in hot water at 70-100°C for 1Omin was adequate to sterilize instruments or equipment and by implication could be considered safe and appropriate practice. Four hundred and seven (94%) of those practices responding had a benchtop sterilizer; 55% had purchased it within the last 5 y, 3% over 10 y ago. The most common type (65%) was SES/Eschmann (Little Sister autoclave) but 11% indicated incorrectly that a hot water boiler fell into this category. The sterilizer was covered by third party liability insurance in 220 (49%) of cases and there was a written procedure in place for its use in 246 (63%) practices. Cleaning and maintenance schedules varied considerably with 162 (37%) carrying these out on a weekly basis but 152 (35%) indicated that these were done less frequently than this or only occasionally. Ninety-one (33%) respondents indicated that the sterilizer was serviced by a qualified technician only when there was a problem
and 30% indicated this was done at intervals of one year or longer. When asked to indicate the position in which a bowl or kidney dish should be placed in a benchtop sterilizer, 187 (43%) replied incorrectly, ie upside down, and only 48 (11%) could provide reasons why the correct position was important, for example to allow displacement of air and steam penetration. One hundred and eight-one (42%) had access locally to a sterile services department and 123 (60%) of the remainder were interested in availing of such facilities.
Discussion
The results of this survey indicate the wide range of minor surgical procedures already being carried out in general practice in the region. There is some confusion, however, over the need for maintenance and the correct use of benchtop sterilizers. This was subsequently confhmed during half day workshops which were conducted throughout the region and which were well attended by GPs and practice nurses. These workshops enhanced the considerable confusion and apprehension that exists over responsibilities in this area. Only 69 of 111 practices had adequate facilities for minor surgery in a survey carried out in Leeds but they considered ‘sterilization by boiling in a custom built appliance’ the minimum acceptable.s There is no guarantee, however, that such conditions will result in the removal of all microbes including bacterial spores, as the temperatures achieved and the exposure time will vary. A review of 24 practices, concentrating on infection control practice, revealed inappropriate use of chemical disinfectants and a lack of detailed knowledge of autoclave test procedures and maintenance.6 Another study of 600 GPs conducted by the British Medical Association (BMA) did not reveal a significant association between the size of the practice and having an autoclave but 22% of high risk instruments were inadequately decontaminated, largely due to the inappropriate use of hot water disinfectors’ but the maintenance of benchtop sterilizers was not, however, covered by this particular study. A subsequent Code of Practice drawn up by the BMA, which advised dividing up procedures and the use of instruments into high, medium and low risk, recommended that autoclaves should be serviced every 3-6 months, routing tests conducted weekly and the results recorded.* A further study of six general practice surgeries, which assessed the understanding of the principle of decontami-
Table 2 Replies on the most appropriate method of decontamination for the surgery
floor and a variety of instruments and articles from the 437 responders Itema Surgeryfloor (C) Thermometer (D) W-he
@I
Vaginal speculum (S) Auroscope ear piece (D) Scalpel (S) Metal forceps (S) Ear syringe (S)
Ring pessary(S) NA: not answered. ‘Letter in parenthesis
indicates
Sterilization
Disinfection
Cleaning
NA
1%
27% 84% 4.5% 3% 62% 2%
62% 5% 0.5% 0% 5% 0%
10%
6% 81% 93% 27% 93% 96% 26% 57% the recommended
1% 53% 29% option,
C cleaning,
0% 15% 6% D disinfection,
5% 14% 4% 6% 5% 3% 6% 8% S sterilization.
GP sterilization KW Allen et al
nation, has also revealed a lack of understanding of the importance of using sterile instruments for carrying out all invasive procedures and revealed deficiencies in the correct use, monitoring, maintenance and storage of decontaminated equipment and antiseptics.g This was reflected in our study in which over half of respondents considered disinfection adequate for ear syringes, instruments which may come in contact with blood. Confusion over instrument sterilization is not confined to the UK; a recent evaluation of dental instrument and device sterilization in the USA revealed that only 68% of items, for which sterilization was considered essential, were sterilized.” Whilst the great majority of respondents in our study indicated that steam under pressure was appropriate for sterilization, approximately one in eight considered that immersion in 2% glutaraldehdye for 10 min was also suitable. Short exposure to glutaraldehyde will kill vegetative bacteria and inactivate most viruses but a 10 min exposure may only kill small numbers of Mycobacterium tuberculosis and a longer exposure, 2-3 h, is required to kill other mycobacteria.” The use of aldehydes in general practice should be discouraged because these compounds are potentially toxic, may sensitize some individuals and appropriate facilities including ventilation are required for their use.i2 Less than half the respondents to our questionnaire were sure of the reasons why wrapped instruments can not be adequately sterilised in benchtop sterilisers. Bags or wrapping should not be used in any autoclave steriliser unless air can be driven out,i3 and this also means that placing bowls or kidney dishes in the upside down position is incorrect. Commercially available benchtop sterilizers used in general practice do not drive air out and a recent Safety Action Bulletin has highlighted this.14 In those practices where minor surgical procedures are performed less often or where it is decided not to have on-site sterilization facilities, the use of a Sterile Services Department (SSD) is an appropriate alternative. SSDs can usually provide sterile instruments for minor surgical procedures, dressings, sets for family planning and even purchase and maintain instruments on behalf of the practice. This will obviate the need for a benchtop sterilizer which is a more complex piece of equipment than is often recognised. During workshops conducted by the authors which followed the survey, there was considerable dismay expressed at the requirement for the initial detailed commissioning and regular monitoring of sterilizers in addition to the keeping of log books, but nonetheless a willingness to improve standards. Furthermore, the extent of the responsibility of the user and the need for insurance is not .always fully appreciated. The response rate from our survey was less than 50% and it is likely that those responding recognised a need for further education; the majority of those circulated, however, may not consider this issue a priority. Individuals managerially responsible for sterilization in hospital or on ,other premises need to be familiar with health and safety aspects, need to ensure that
117
of instruments
personnel at all levels have a general knowledge of the principles involved and need to have a designated competent person for regular inspections.‘5 We believe that greater attention needs to be focused on surgical facilities in general practice and there is a need for ongoing education in this area. Ultimately, higher standards might best be achieved in the form of accreditation SPecifiCally for sterilizing procedures, at regional or national level, after a process of training and inspection with Particular emphasis placed on the purchase, care and maintenance of bench top sterilizers.
Acknowledgements We wish to thank the TRWPSD for their support, J Buckle for help in collating the results and finally, those who returned questionnaires. We are grateful to Mr RA Needham for his assistance in conducting the workshops.
References 1 LOWE A et al. Minor surgery by general practitioners under the 1990 contract: effects on hospital workload. BMJ 1993; 307: 413-417. 2 GP Fund-Holding Practices: The Provision of Secondary Cure. Health Services Guidelines. NHS Management Executive 1993; HSG (93) 14. 3 Kneebone RL. Training general practitioners in minor surgery. Br J Gen Pratt 1994; 44: 103-104. 4 Transportable Steam Sterilisers: Maintenance, Inspection and Insurance. Safety Action Bulletin: London, 1992; No. 82 (92) 27. Zolte N, Hoult G. Adequacy of general practitioners’ premises for minor surgery. BMJ 1991; 302: 941-942. Hoffman PN et al. Control of infection in general practice: a survey and recommendations. BMJ 1988; 297: 34-36. Morgan DR, Lamont TJ, Dawson JD, Booth C. Decontamination of instruments and control of cross infection in general practice. BMJ 1990; 300: 1379-1380. 8 A Code of Practice for Sterilisation of Instruments and Control of Cross Infection. British Medical Association: London, 1993. 9 Rogers J. Sterilisation in GP surgeries. Nurs Times 1989; 85: 65-69. 10 Gurevich I, Dubin R, Cunha BA. Dental instrument and device sterilization and disinfection practices. JHosp Infect 1996; 32: 295-304. GAJ, Babb JP, Bradley CR. ‘Sterilization’ of 11 Ayliffe arthroscopes and laparoscopes. J Hosp Infect 1992; 22: 265 269. 12 Babb JR. Chemical disinfection and COSHH: safe and effective work practices. J Steriles Services Management 1990; 1 (July/August, No. 10): 9-12. 13 Wood PR, Martin MV. A study of the use of autoclave bags in non-vacuum autoclaves. J Dent 1989; 17: 148-149. 14 ‘Instrument and Utensil’ Steam Sterilisers: Misuse. Safety Action Bulletin: London, 1989; NO. 52 (89) 73. 15 Sterilisation. Part 1. Management Policy. Health Technical Memorandum 2010. NHS Estates: London, 1994.