Sterilisation for home visits

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How does one find out about the up to date sterilisation procedures for domicillary chiropodists in the U.K., my professional body was not a lot of help.
If one looks on forums like these and others there is a lot of contradictary advice and a lot of the guidelines and procedures are for the NHS, I am a private, self-employed chiropodist.
Looking at the DOH there are a lot of other sites to look at, HSE, RCN, MHRA & OPSI, for example but to have to trawl through it all to find what is relevant is mind blowing and how can one tell at the end of the day you are doing it correctly. After looking at some of these sites, I could interpret it differently to someone else, it was suggested that the HPC would advise but they are only our regulator.
Help ???

 

Re: springyfeet

Hello Springyfeet,
I am more than a little concerned when you say that "your professional body wasn't a lot of help."
Surely they must have some protocols/guidelines in place to help their members?
I would suggest you contact the secretary of your organisations' local branch and make yourself known. I am sure they must have training days, seminars and CPD courses to assist members with these types of queries.
Regards
Dido

 

Hi,

Sterilisation for domiciliary is no different from sterilisation for clinic.

As far as I'm aware there is no legal specific requirement for the UK currently, hence the HPC's lack of knowledge/interest.
Obvious sensible measures though are autoclaved instruments (one set per pt), gloves etc.

Contradictory advice would seem to be originating from imisleading information put out by autoclave manufacturers trying to sell expensive all-singing all-dancing autoclaves with built-in printers.

Who is your prof body BTW?

 

Working in the British NHS we now use only prepacked instruments sterilsed by the acute hospitals big theatre autoclaves with sticky labels to put in notes for all our work - is it worth asking if they would be interested in your business at least then you are sure of meething the constantly chaning EU regulations. An alternative or two is for patients to have their own instruments they are responsible for - some NHS trusts do this, or to use disposable instruments (we do this with some sessions for scalpels and scissors) and pass the cost on. Kim

 

HI David,
We were told that in a surgery/clinic you do not need to pouch them, as long as the insruments are used within 3 hours but a visiting practice would need to pouch them.
Where does one go to verify if these instructions are correct and what the right procedures are ?, only given guidelines not protocols and when questioned them, did not recieve a satifactory reply. How can one tell if they are doing the correct things or not ?.

 

Hi,

I'm afraid there are only guidelines and rumour available.

Stick to the guidelines. Your instruments must be autoclaved (ie one set of autoclaved instruments per patient), and should be scrubbed before being autoclaved. An ultrasound bath is a good idea, but not mandatory. There is no legal or statutory requirement for instruments to be bagged for domiciliary use. If you can run to a vacuum autoclave which will allow you to bag your instruments, then fine, but you do not have to. Blades of course are already pre-packed and sterile.

Approaching the HPC shows due care and regard for your patient welfare, and if you seek advice from them, do so by letter and store their reply safely.

If you are a member of my professional body (SMAE/BCPA) go onto our forum and do a seach on "autoclave". The relevant, correct and up-to-date information is all there.

The NHS have specific and robust protocols for instrument sterilisation.
As Kim has suggested, having batches of instruments sterilised and bagged by CSSD may be a way forward for you, but the cost may be prohibitive, and do bear in mind that NHS sterilisation protocols are, in the main, written for invasive procedures, and not the type of work you will be doing in domiciliary footcare.

Regards,

David

 

Hi David,

Thanks for your reply, thats why they cannot give protocols or legal requirements then, that it is for the NHS and in private practice can only follow guidelines given.
That would be our best practice policy, interesting to note that pouching is it not necessary as long as autoclaving instruments. Will make a note for my file, in case asked in the future.

 

In the NHS dept I work for, we still do autoclave instruments for home visits but the 3 hour rule also applies to us here. However, a collegue of mine who has been considering private practice has decided that all her patients will purchase a disposable nail care set on their first appt (home visits only) They will keep these sets in their home and will be used only on themselves when visited by the podiatrist.?? any thoughts?

 

Good idea will mull over the pro's and cons. thanks

 

Only that some patients may be put off by what they see as a cost-cutting measure on behalf of the Pod ("why should I pay for a set of instruments to save him/her the cost of sterilisation").

Nice idea on paper though. Be interesting to hear the feedback.

Regards,

 

well, I think the thought behind it would be that it would save the patient in the long run as costs of sterilisation etc wouldnt be passed on each time to the patient, plus they would belong to the patient to use themselves if they wish....

 

Cheesy
My thoughts on disposable instruments for Doms is that it is totally impractical, unprofessional ( puts a pod at the level of age concern nail cutters who dish these instruments out), and will give the Pod repetitive strain very quickly!

How would the Pod adjust the fee to reflect the patients having their own unsterile instruments? What if the nails were pathological with a tendency to ingrow and the chance of a breach in the skin?

Regards

Cornmerchant

 

Cheesy

So if I understand correctly, what you propose is that its ok to infect the customer with their non sterile tools as long as its with their own bugs and not those of the last patient. What about bugs from the customers dog does that count as cross infection?

The SCP has good guidelines on DoM and sterilisation protocols on their website. They are not a stringent as you might imagine and rumour proposes but will be quite sufficient if you follow them.

Here's a good site where you can do reading CPD in infection control - The infection control education institute http://www.iceinstitute.com/ I have used it for several years and found it a very useful source of CPD.

Cheers Dave

 

Hi,
What do you think about the type of autoclaves that are available, do you think that the smaller / cheaper ones are just as effective as the more expensive models?
iIwould appreciate anyones comments
Cheers Claire

 

"What do you think about the type of autoclaves that are available, do you think that the smaller / cheaper ones are just as effective as the more expensive models?"

IMO no.
You get what you are prepared to pay for.
If your auoclave has a printer then you can prove that every cycle has reached the correct temperature.
If you are undertaking home visits then you need a big enough autoclave to process at least 6 sets of instruments when you return home for lunch.
If ever there was a claim against you, you would be judged against best practice, so it is worth bearing that in mind.
I would take advice from your professional organisation about this as I am sure they will have a written set of protocols.
Dido.

 

Thanks for your input

 

Oh dear and my goodness,
I guess if you dont know you dont know but in my practice in Aust, we have 10 sets for the clinic (and they dont leave because inevitably they are damaged on home visits ) and 30 home visit sets. All autoclaved in seperate pouches ( 1 clipper 1 nail dresser 1 scalpel handle 1 blacks file 1 beaver handle and blade 1 burr and 1 mandrell )1 set per patient strict rule including burrs and mandrells for automated nail drills .... it seems coomon sense to me for no cross contamination ... but thats the way i was trained I guess.
Hey if you want us Aussies to come over and do some consulting just let me know.
Cheers Lorraine

 

I don't do any home visits but have two offices. I use two Ritter M9 Autoclaves and peely pack my instruments in sets for routine care. My burs and beaver handles etc. are packed individually.

The ONLY way to sterilize for sure is with a steam autoclave.

regards

 

I would be concerned to leave a pack of instruments in a clients home for them to care for. they could be using them on their dog, cat, aunt or uncle. If you treat them and they get an infection they will still hold you responsible if you did the treatment. Personally i only use pouched instruments, and then if someone where to have a problem i have a paper trail to back me up. I recently met a lady who is paid by a charity to cut nails in the local hospital with a set of instruments for each client paid for by the NHS ( i think ) and supported by GP's, these instruments are not autoclaved between treatments, just "sprayed with antiseptic before use", her insurance is paid for by "funding" she has no qualifications and one days training (from an NHS podiatrist), she had no concerns over her practice and felt she was doing the NHS and the clients a favour. Where does this leave us? Where does this leave the patient? just a few thoughts.

 

Hello Ed,

This is what really ticks me off. I am expected to jump through hoops to satisfy the HPC requirements and yet there are persons 'out there' performing footcare to lesser standards.

What can we do about it? Nothing.

It would take a serious negligence claim to change the system and I wouldn't wish that on anyone.

 

I came across this thread this morning and it reminded me of a genuinerequest from a patient I was visiting. He asked me if I would cut his cat's claws! I think that demonstrates that, any instruments left in the patients home are likely at some point to be used inappropriately.

In addition, what is to stop patients having a go at their own feet with the instruments they have purchased from you? How could it be proven who was to blame, without taking a digital photo at the end of every session?

If instruments are supposed to be sterile immediately before use, and they are, how can it be acceptable to use unsterilised instruments just because they remain in the patient's own home?

 

I must admit to preferring the description that we "decontaminate our instruments", sterilisation by autoclave being only one part of this process. This enables instruments free of contaminants, but not necessarily sterile, to be used at the point of contact with the patient. For general practice this is all we need. A proven and documented decontamination process is good practice for those of us who do not choose single use disposable instruments.

Ran into a very dodgy situation this week.

Locally we have a Social Care Enterprise (SCE), Caremart, who have taken over nail care in much of the NW of England. Originally trained by NHS staff, they are partners with the NHS and the preferred alternative providers of footcare (see DoH definition of footcare) to discharged NHS Podiatry patients.

A home that I have had contact with in the past uses Caremart's services every 5 weeks. (I withdrew from providing general services to homes on grounds of neck pain. I recommended an alternative Pod). They have 40 residents and have provided 1 set of dedicated instruments for use at the home. The residents and relatives believe these operatives are trained Chiropodists/Podiatrists. It is a service they have to pay for. There is no direct access to a Podiatrist and they do not follow up other foot problems unless they are absolutely obvious. In other words Caremart nail cutters will seek support from a registered Podiatrist if they recognise there is a problem. They will advise their client how to find a private practitioner or advise the patient how to register for NHS podiatry.

This situation is reflected across the residential and nursing homes within the areas where Caremart is active. As with other SCEs the service user, when not resident in a home, purchases their own dedicated set of instruments. In this situation it is the service users responsibility to decontaminate their own instruments.

During the last week a resident, once a patient at my clinic, developed a foot infection and it became an "emergency" situation. I would not involve myself, duty of care or no duty. I do not know if this was caused by other footcare workers and for self protection I don't want to know.

Due to this lack of instrument decontamination, I have now made it practice policy to refuse to attend patients in homes serviced by Caremart where residents have developed acute foot conditions and require the services of a Podiatrist. If Caremart are the preferred partners of the NHS then it is the NHS' duty to provide emergency Podiatry services and deal with the aftermath if a "blame situation" occurs.

This is why the article written by Andrew James, SCP Policy Officer, Wales which was published in July 2010 Podiatry Now leaves me rather cold. I apologise for not being able to provide a copy for non SCP members. He outlines that PP members are concerned about the impact of nail cutting services by not for profits on their businesses when in my opinion most of us seem concerned about the lack of standards these elderly folks are exposed to and what happens when acute podiatric conditions arise. Proposals have gone forward in Wales for a nail cutting scheme which does address concerns about decontamination and the need for Podiatry input but as with all these "ideal" schemes, who enforces them?

It is my opinion that attempts by SCP to control standards of footcare is too little and about 4 years too late. I know other professional bodies have been vocal on this issue but it seems their attempts to influence standards have been even less effective.

Probably many will not agree with my stance but trying to function within this fragmented profession it is now about self protection rather than relying on regulation to ensure standards.

Very sad as this acceptable commercialism by SCEs affects the most vulnerable of our society.

GB

 

GB,
Well, we all knew this was going to happen didn't we? We raised our concerns and they went unheeded.

Sadly, I suspect that this is not an isolated incident.

I could not agree more.

Sadly, I would agree with this as well. In this litigation-conscious society we need to be very vigilant and practice to the highest standards we can. Unfortunately the cost of this will need to be borne by the service user.

This is the most worrying aspect of this type of footcare.

CF

 

For the last 2 years I have been organising the Servicing and Calibration of autoclaves for my local SMAE/BCHA branch. This is due again in November. I am now really unsure as to what to advise my colleagues, mainly because of all the literature that comes through my door about sterilization temperatures,printouts etc. In the main, most of us are using Prestige models and operate in the domiciliary field. The literature comes exclusively from SUPPLIERS telling us what we NEED. It appears from various threads that there are only recomendations and not strict rules/laws. We all want to practice safely. Do I need to tell them to bin their existing equipment and buy new all singing and dancing stuff ?

Any solid advice on this would be really appreciated.

This is my first thread reply, so bee gentle please.

Ian Bees

 

Hello Mr Bumble,
May I suggest that you go back to SMAE and ask their advice?
They are the organisation that provides the indemnity insurance for their members, so they would be involved with the payout in the event of any claim.
regards
CF

 

It is an interesting point and i do carry a camera with me on home visits and in the clinic, i gain consent and then photograph before and after treatment. I especially do this if i suspect dementia or if the patient is unable to see the problem themselves (if it is on the plantar surface)Not only does this act as a record but it also provides a bench mark for further reference if i wish to assess treatment outcomes in this way.

 

All,
Back to George Brandy's post of 19th Sept

This is a totally unacceptable situation but seems to be perfectly legal.

If the home concerned are not giving their residents informed choice regarding footcare provision then they are failing in the Duty of Care. This looks like a case for the CQC.

CF

 

Quote:
The residents and relatives believe these operatives are trained Chiropodists/Podiatrists.

Not necessarily. Remember these are the most vulnerable people in our society and the reason regulation exists. What the owner of the home says/ does/ provides in written format is so easily forgotten unless constantly reinforced.

Had I not been a part of this fragmented profession, I would not have known or realised the number of different providers of footcare. I probably would have assumed someone cutting my elderly relatives toenails within a care environment and being paid was a Chiropodist. I would have assumed that with most healthcare provision there were certain level of standards of hygiene, including sterilisation given the fuss over hand washing and all the hoohar in hospitals and health centres over the nasty infections that wipe out our elderly.

I don't think there is anything wrong with these assumptions, nor with the care home not constantly reinforcing what these nail cutters can and can't do.

In my opinion it just proves how regulation is a complete failure in protecting the public. The Government and its quangos puts it in place and neatly steps around it.

GB