Hospitals are putting lives in danger by failing to implement rules designed to minimise the risk of patients accidentally contracting fatal infections through surgical instruments contaminated in previous operations, NHS advisers reveal.
Surgical teams are failing to keep instruments in sets that can be easily traced if infection does spread in this way, and are swapping pieces of kit between sets.
The consequences could be fatal in high-risk operations such as under the protective lining between skull and brain or on the back of the eye where there are easy routes for spreading neurological disease. More than 50,000 such operations take place in England and Wales each year.
Experts, who want new checks to ensure the rules are not flouted, believe cleaning and decontamination of instruments is also still substandard, despite attempts by the Department of Health to close this avenue of spreading diseases.
It introduced rules to improve cleaning, tracing and quarantining of equipment in 2000, and tightened them in 2003 after a CJD scare at Middlesbrough general hospital. It also encourages the use of disposable instruments where possible. Checks before Middlesbrough suggested that cleaning in the 250 English hospitals with sterile services units was at least acceptable, after earlier spot checks had revealed severe shortcomings. These had also shown problems with tracing equipment, but measures such as bar-coding were meant to bring improvements.
But advisers drawing up draft guidance on preventing cross-infection with CJD diseases found hospitals were still failing to keep separate instrument sets. Their report for the National Institute for Health and Clinical Excellence (Nice), completed last month, said it was "most important that systems are put in place to ensure no instruments are swapped between sets in high-risk procedures and that the effectiveness of these systems is demonstrated through regular audit".
The advisers found limited information on the extent of instrument swapping but that available suggested there was a 50% chance of at least one instrument ending up in a different set after each operation. No system of decontamination will yet completely remove the prion proteins associated with CJD infections but proper cleaning, brushing and high pressure sterilisation can lower infection risks substantially for high-quality instruments not available in disposable form.
Separate instrument sets were also needed for children never exposed to the risk of human BSE through eating meat at the height of the cattle BSE epidemic. Officials are urgently calculating how much the package will cost.
A Department of Health spokeswoman said it took "instrument migration" seriously and had stressed the need for "rigorous implementation" of washing, decontamination and general hygiene, which were now included in the assessment of NHS trusts.
Graham Steel of the CJD Alliance, a group including relatives of patients, said: "It is far from reassuring to learn that in real terms nothing has changed."
Four cases of CJD spread through contaminated surgical instruments have happened in Britain, all over 30 years ago. No similar cases have come to light recently, but there are persistent worries that variant CJD, the human form of BSE, can spread the same way, and that there are thousands of unknowing carriers of the long-incubating disease.
