Strategies for Low-Resource Settings

In low-resource settings, there are a number of factors to consider when deciding on the appropriate instrument processing routines. Availability of supplies, reliability of electricity, equipment maintenance, and other issues will factor into your decision about which processing methods are most appropriate for your facility. It is likely that you will need to have more than one method available in order to adequately process all items used at your facility.

Remember: Sterilization is preferred for instruments or other items that come in contact with the bloodstream or tissues under the skin. If sterilization is unavailable or impractical, HLD is the only acceptable option for these items.

In deciding on the most appropriate method for your facility, remember:

• If possible, your facility should obtain an autoclave for steam sterilization. Steam sterilization is appropriate for most items. In addition, linens (such as surgical gowns and drapes) and liquids (such as water) can be adequately processed only using steam sterilization. All autoclaves require a source of clean water and a constant supply of heat, but whether electricity, kerosene, or another fuel is needed depends on the type of autoclave being used.
• Dry-heat sterilization (electric oven) requires a reliable source of electricity and can only be used for sterilizing glass and metal objects. This method may not be the best option if your facility often loses electrical power, since items will have to be reprocessed if sterilization is interrupted by a power outage. In addition, you must be sure that another method is available for plastics and other items that cannot be processed using dry heat.
• Chemical ("cold") sterilization requires an adequate supply of a chemical sterilant solution (such as a glutaraldehyde-containing solution) and sterile water. This method is useful for processing heat-sensitive items, but is not appropriate for all items. You must be sure that another method is available for items that cannot be processed using chemicals.
• HLD by boiling requires only clean water and a heat source. Many facilities choose to use this method as a backup to their primary method of sterilization, but it is not appropriate for all items. You must be sure that another method is available for items that cannot be processed through boiling.
• Chemical HLD requires an adequate supply of a high-level disinfectant (such as chlorine or glutaraldehyde-containing solutions) and boiled water. This method is useful for processing heat-sensitive items, but is not appropriate for all items. You must be sure that another method is available for items that cannot be processed using chemicals.
• HLD by steaming requires a tiered steamer, clean water, and a heat source. This method has been shown to be effective for processing gloves and MVA cannulae, but it is not appropriate for all items. You must be sure that another method is available for items that cannot be processed using steam.

Have a back-up method of sterilization/HLD available

It is important for your facility to have a backup method that can be used if your primary method of sterilization or HLD is unavailable due to power outages, equipment failure, supply problems, or other factors. Many low-resource settings choose one or more methods of HLD as a method for times when the primary methods of sterilization are not available.

Make sure that the staff who process instruments and other items used during clinical procedures are familiar with the steps of both the primary and backup methods and know how to correctly process all items used at your facility.

Addressing equipment and supply problems

Every facility faces different problems. Whenever possible, try to find the simplest, most low-tech solution. Assemble a team of administrators and staff to work on strategies that will ensure adequate supplies for instrument processing. Have them ask:

• What is the real source of the problem?
  Equipment: Do your evaluation indicators often show sterilization failure? Is it because of faulty equipment or incorrect processing procedures? Do items often have to be reprocessed because of poor handling or storage problems? Is your autoclave or oven breaking down because it is not being properly used and maintained? Do staff understand the appropriate steps for use and maintenance? Are there adequate funds to purchase an autoclave or electric oven?
  Supplies: Can you budget enough money to order adequate supplies? Are new supplies being ordered before existing stocks run out? Does your supply of disinfectant run out because staff are storing items in disinfectant solution or otherwise using disinfectants inappropriately? Do shortages of running water interfere with your ability to process items?

• Is there a simple, low-tech solution?
  Equipment: If sterilization failure is cause by faulty equipment, is the machinery being properly maintained? Is there a local resource for repair and maintenance of equipment, and if not, can you arrange for staff training in these skills? If failure is caused by incorrect processing procedures or poor handling, can you institute on-site training in these skills? Can you rearrange your processing room and storage area to minimize the risk of contamination? Is there a way to obtain funding for the purchase and maintenance of new equipment? Would it be more or less costly in the long run to pay an outside source to process items for your facility or to purchase and use your own equipment?
  Supplies: Is a less expensive disinfectant available for decontamination and chemical processing? How can you modify current ordering procedures to ensure a steady flow of supplies? Is staff training in the proper use of supplies possible? If shortages of running water are common, can you store a clean supply of water for instrument processing?

  
  

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