Infection Control and Professional Nursing in China

from Caring For Our Future, Summer 2004

By Rose Seavey RN, MBA, CNOR, ACSP, Director, Sterile Processing Department

The Invitation: A Chance of a Lifetime

In November of 2003, Advanced Sterilization Products (ASP), a Johnson & Johnson Company, decided to launch a new low-temperature sterilizer, STERRAD System 1, in China. In order to educate the Chinese healthcare workers about the equipment, experts from the U.S. were contacted and asked to travel to China to share their experience. ASP’s Director of Global Market Development asked me to travel to three cities in China to present lectures on new sterilization technologies. I traveled with Dr. Martin Favero, ASP’s Director of Scientific and Clinical Affairs, to Chengdu , Wuhan and Beijing in China for 10 days in November 2003.

Therefore, The Children’s Hospital in Denver has used the STERRAD System 1 exclusively since 1996 for sterilization of these items. There are a wide variety of medical and surgical items that cannot withstand the high temperature and moisture associated with steam sterilization. Therefore, The Children’s Hospital in Denver has used the STERRAD System 1 exclusively since 1996 for sterilization of certain items. Items that must be sterilized with this method include delicate microsurgery instruments, electronic equipment, cardiac catheters, all flexible scopes (i.e., endoscopes), anesthesia equipment and respiratory supplies. As technology advances, it is likely that more new devices will need this particular type of sterilization.

Ethylene Oxide (EtO) gas used to be considered the sterilization method of choice for these sensitive devices, but there were several concerns about the economic and environmental impact of using EtO gas over time. The Children’s Hospital was the first hospital in Colorado, and one of the first in the United States , to totally eliminate the use of EtO gas in favor of the STERRAD system.

My presentation focused on the increasing need for low-temperature sterilization and the elimination of EtO gas. I shared with the Chinese how The Children’s Hospital was successful in becoming more economical while making the environment safer by switching to a new low-temperature sterilization technology and using the STERRAD System 1.

Sterilization advances over the past half century EtO gas was first used as a sterilizing agent in the 1940s. EtO gas was the first substance to secure successful sterilization of temperature- and moisture-sensitive medical devices. In its pure form, EtO is extremely flammable and explosive and requires special handling. To decrease some of these fire hazards, the manufacturers mixed carrier gases, such as carbon dioxide, chlorofluorocarbons (CFC), and hydro chlorofluorocarbons (HCFC) with the EtO. However, in 1987, The Montreal Protocol on Substances that Deplete the Ozone was written to stipulate that the production and consumption of compounds that deplete ozone in the stratosphere – chlorofluorocarbons, halons, carbon tetrachloride and methyl chloroform – were to be phased out by 2000.

Eliminating the carrier gases only solved part of the problem. When EtO is used as a sterilizing agent, a significant amount of money must be budgeted for abatement recovery systems that will either recycle EtO or turn it into a harmless byproduct. EPA regulations regarding EtO disposal vary from state to state and country to country.

The EtO sterilization cycle requires four hours of product exposure to the gas. Eliminating EtO residue from a product and its packaging requires aeration, either in the sterilizer or in a heated cabinet designed for this purpose. This procedure involves another 8 to 12 hours. In some facilities, this means only being able to use instruments once a day. This is not very efficient or cost-effective.

In addition to being expensive and time-consuming, EtO is toxic to humans. If inhaled, EtO is moderately to severely toxic, depending on the concentration and exposure duration. Exposure to EtO can cause respiratory irritation, lung damage, headaches, nausea and vomiting, diarrhea, shortness of breath, and, at high concentrations, respiratory arrest. OSHA requires records be kept on all employees who have worked with EtO for at least 30 years after their separation from the facility.

Because of the concerns associated with EtO, in the early 1980s a safer and more cost-effective alternative was developed. This new technology sterilizes with a combination of hydrogen peroxide vapors and low-temperature gas, and is called “STERRAD System 1.” Hydrogen peroxide gas plasma sterilization uses ions, electrons and neutral atomic particles to safely and effectively sterilize without the risks associated with EtO.

STERRAD System 1 is safer and less expensive than EtO. The total sterilization cycle takes about 55 minutes and needs no aeration or abatement. Therefore, technicians can run about 14 STERRAD System 1 loads in about the same time it takes to run and aerate one EtO gas load. Hydrogen peroxide gas plasma vapors break down into non-toxic substances such as water, oxygen, hydrogen and argon. With this system, we are helping to make Children’s a safer place for patients, employees and the general public.

Changes in Attitude Regarding Infection Control in China

Healthcare in China is changing. China is a centrally planned, socialist country moving toward a market economy. This capitalistic momentum is helping to change the healthcare system in a positive way. China extends approximately 3.7 million square miles, and is slightly larger than the United States . The country has more than 1.3 billion inhabitants and is the most populous nation on earth.

Dr. Favero and I visited and presented our lectures in the three cities. Each audience consisted of 80 to 100 operating-room nurses, doctors, infection-control practitioners, sterile-processing professionals and government officials. Through an interpreter, I presented information about the STERRAD System 1 and its advantages over EtO gas sterilization, while Dr. Favero, who worked for the Centers for Disease Control and Prevention (CDC) for 32 years before joining ASP, lectured on infection-control issues in China.

Dr. Favero said there were 50 million inpatients in China each year and that 10 percent, or 5 million, develop infection. Of those infections, 40 percent are respiratory, 30 percent are urinary tract, 10 percent are surgical site, 10 percent are gastrointestinal, and 10 percent are other types of infections. Twenty-eight percent of the pathogens are gram positive, like staph aureus or streptococci, and 48 percent are gram negative, like pseudomonas.

Dr. Favero shared findings from a study that took place in one Chinese hospital. In this hospital, newborn infections were on the rise. Ten newborns died of toxic dysentery within a relatively short period. In addition, there were 70 patients who died from other infections. In the study they discovered that contaminated syringes and surgical instruments caused these patients’ infections. Data showed that these items were contaminated with water bugs such as pseudomonas. Further investigation revealed that the glutaraldehyde solution used to sterilize these items was at a 0.1 percent concentration. In order to be economical, the hospital staff had made their own solution. The recommended strength for glutaraldehyde solution is 2 percent to 3 percent. This low concentration of solution allowed TB and other bugs to grow at very high numbers, causing infection and death in several patients. Due to this study and other such studies, the Chinese are starting to pay more attention to hand-washing and infection-control routines in their daily practice.

What We Learned About Healthcare in China

After each lecture, we had the opportunity to have dinner with the participants and learn about their healthcare practices. The majority of the Chinese population is covered by socialized medicine; however, commercial insurance is on the rise as more Chinese citizens are able to afford it. The reimbursement structure in China is fee-for-service, so the longer a patient stays in the hospital, the more money the hospital makes. Chinese surgeons do far fewer elective surgeries than their counterparts in the U.S. The waiting list for elective surgeries is an average of four weeks. The target or average length of stay in a Chinese hospital is two weeks. If a patient has a major surgery such as a joint replacement or an open-heart procedure, he or she is usually in the hospital for 45 days. When a woman delivers a child, she can count on being in the hospital for 10 days to two weeks. While the patient is in the hospital, his or her family members perform most of the daily tasks like feeding and bathing. Unfortunately, these longer hospitalizations lead to an increased risk of nosocomial infections.

In China, the government only allows one child per family. While conversing with one Chinese nurse, I questioned whether the government requires a tubal ligation after a woman gives birth. The answer was, “No, that is too dangerous due to the infection rates.” All mothers in China are required to be on birth-control pills. She said most of the women hate the side effects, but if they get pregnant and have another child, they will not be allowed to work. In China , it takes at least two incomes to raise a family.

In China, the nursing profession is highly respected. They require a five-year education and a bachelor’s degree to become a nurse. Although the educational requirements are rigorous, I was told that there are too many nurses in China . The new grads are not able to find jobs, and the mandatory retirement age for nurses is 55 years old. In China , nurses are required to wear uniforms and caps. The pay for new grads starts at about $200 in U.S. dollars per month. Measured against a 40-hour work week in the U.S. , they earn $1.25 per hour. Nursing specialties, such as ICU and OR, are recognized with higher pay.

Despite our differences, the Chinese nurses and healthcare providers were very interested in our presentations. They were enthusiastic about improving their infection-control rates and transitioning to a new sterilization system that is both economically and environmentally safer.