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Hospital Healthcare Europe

Bedpans and healthcare-associated infections

Gertie van Knippenberg-Gordebeke
31 July, 2012  
Gertie van Knippenberg-Gordebeke RN CCIP
KNIP: International Consultancy
Infection Prevention
Venlo-Boekend, the Netherlands
Patients can commonly be denied access to improved sanitation and proper bedpan management, putting them at increased risk of healthcare-associated infections (HAIs). There is a worldwide increase of outbreaks owing to resistant bacteria, such as vancomycin-resistant enterococci (VRE), methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Klebsiella pneumoniae and Pseudomonas aeruginosa. These pathogens are difficult to treat with standard types of antibiotic and therefore more dangerous to patients. Outbreaks are often the result of poor hygiene, which can be prevented by basic infection-prevention measures such as hand hygiene and effective cleaning and disinfection of reusable medical and nursing devices.(1) 
It is estimated that 10% of patients are carriers of multidrug-resistant microorganisms. These reservoirs on the skin and in the colon are not evident and not always tested for when the patient is admitted to hospital. Therefore, all patients must be treated as infected or colonised. Faeces contain billions of microorganisms and many bacteria leave the body with the stool. During episodes of diarrhoea, the bacterial load is even higher and can include spores of the difficult-to-eliminate Clostridium difficile (C. diff).(2) Manual emptying of bedpans and urine bottles into a slop hopper sink or toilet is still carried out routinely. It is an underestimated, unpopular and labour-intensive task for caregivers, who are mainly the nurses and nursing assistants. This practice, with its risk of spreading microorganisms directly to the environment or indirectly via healthcare personnel, has been ignored for a long time. Studies on managing bedpans as possible reservoirs and as transmission routes are limited.  
Semi-critical or non-critical?
The Netherlands classes bedpans as semi-critical items, unlike in Spaulding’s 1968 decontamination scheme.(3) This scheme categorised bedpans as non-critical items and in the same category as blood pressure cuffs. Conforming to this scheme of cleaning and low-level disinfection should be sufficient because non-critical items should not come into contact with mucous membranes or non-intact skin. However, there are concerns about implementing the Spaulding scheme because no attention is paid to the heavy bacterial load of the contents of bedpans, urinals and urine bottles. The fact that bedpans have to be emptied before the decontamination process – with the risk of splatter, splash and aerosol – is not taken into account. 
A Dutch survey carried out in 1990 showed poor results in bedpan management despite using washer disinfectors (WDs).(4) The findings resulted in nationwide recognition of the problem and, in 1995, guidelines for WDs were developed by the Dutch Working Party Infection Prevention.(5) 
In 2006 the International Organisation for Standardisation (ISO) introduced a six-part technical yardstick for cleaning and disinfecting appliances using WDs: ISO standard 15883.(6) Part 2 of the guideline, which covers  WDs for thermal disinfection for surgical instruments and anaesthetic equipment, is  accepted internationally and Part 4, which covers WDs for thermolabile endoscopes, is used widely. Part 3 specifies requirements and tests for WDs employing thermal disinfection for human waste containers (for example, bedpans) and it is unclear why less attention is paid to this part. To check improvements and knowledge and to identify the resource availability of bedpan management, the survey was repeated in 2010 in 54 countries. 
Bedpan management
Basic hygiene to guarantee safe sanitary care for bedridden patients must include bedpan management. Defaecating and urinating are normal processes and managing a bedpan is regarded as an essential part of care that may vary depending on habits and budgets. The infection control team must introduce best practice methods. With macerators or WDs, maintenance and validation reports must be checked. Written protocols and specific training must be developed for bedpan and  urine bottle care and applied unconditionally in all healthcare situations and by all personnel, regardless of patients’ diagnoses. The ward manager is responsible for ensuring that all staff who handle bedpans receive appropriate education.
Safe bedpan management requires a standardised approach and can be described in seven steps. 
Step 1: patient bedpan care
With regard to ethical and hygienic standards, every patient has the right to receive clean items. Open plastic (synthetic) bedpans are being used worldwide as they are inexpensive but there is a risk of contaminating hands and the environment. In north-west Europe, stainless steel bedpans with a lid and a firm grip handle are mainly used; these fit comfortably in one hand and the lid prevents contaminating the hands and environment. Hand hygiene must be performed directly after taking sanitary care of the patient, and alcohol handrub must be available within arm’s length of the action. Disposable gloves worn during contact with the patient must be removed in the patient’s room. 
Step 2: from patient to sluice
Many countries have regulations to ensure that faeces and urine specimens are transported to laboratories in specially designed closed containers to protect the carrier and the environment from contamination. By contrast, there are no regulations for carrying a full bedpan or urine bottle to the location where it is emptied. Open bedpans without a lid are difficult to handle without contaminating the hands. Stainless steel bedpans with a lid prevent contaminating the environment and the hands.
Step 3: emptying  
Bedpans and bottles are in use 24 hours a day, seven days a week – a normal practice for which the risk is not recognised routinely. Manual emptying and flushing is a high-risk procedure for spreading and transmitting microorganisms. Personal protective equipment, such as gloves and aprons, must be used to avoid contact with body fluids. Emptying urine and faeces in a toilet or slop hopper carries a risk of contamination of the hands and the environment. Biofilms, which appear as slimy material with an unfresh odour, are major reservoirs of microorganisms in slop hoppers. To avoid contamination, manufacturers have designed machines that can be placed in a sluice room or in a room connected to the patient’s room. 
Macerators (also called destructors) are designed for disposable pulp bedpans and bottles. After depositing the full bedpan/bottle in the machine, the door closes and the machine empties and crushes the pulp bedpan, the remains of which are mixed with the human waste and which flow to the sewage system. Disadvantages to this system are that macerators must be maintained regularly and stock management of the disposable items requires space and continuing costs. 
Washer disinfectors are designed for reusable bedpans. The contents including toilet paper is emptied when the door of the machine is closed. The WD is connected directly to the sewage system and the soiled content is flushed away. The decontamination cycle involves rinsing, cleaning and heat disinfecting to destroy most microorganisms, and is finished with a drying cycle. 
Step 4: cleaning
The cleaning process is essential to remove dirt before the disinfection phase. Failure to perform good cleaning can result in failed disinfection, leading to outbreaks of infection. Open plastic (synthetic) bedpans have to be renewed if the surface is no longer smooth because even the smallest damaged area can harbour bacteria. Stainless steel bedpans are long-lasting and are easy to clean. Manual cleaning is never a standard operating procedure. Flushing or rinsing with water is insufficient and using a spray nozzle leads to the spread of pathogens. Manual cleaning should be avoided wherever possible. 
Step 5: disinfection
Disinfection is achieved with chemicals or heat and must always be preceded by mechanical or manual cleaning.(7)
Chemical disinfection reduces the numbers of microorganisms but there are many disadvantages with this time-consuming system such as contact time, and incorrect choice of disinfectant and solution strength and adequate results are not always guaranteed.  Residues must be removed after disinfection. 
Thermal disinfection is preferable to chemical disinfection and achieves high-level, non-toxic disinfection when surfaces are in contact with heat above 80ºC (176°F) for an appropriate length of time. WDs are designed for thermal disinfection.(8) Good quality WDs that adhere to Part 3 of the ISO Standard 15883 have many benefits, including removal of all residues and greater reliability than chemical disinfection. Validation, regular maintenance and continuous monitoring guarantee the disinfection process. 
Step 6: drying 
Drying is essential to prevent growth of microorganisms. Any residual fluid can become a potential reservoir.
Drying by hand after the decontamination process is essential if using a manual process. The drying cloth can easily become contaminated and it is recommended that disposable cloths be used.
Mechanical drying in the WD should deliver a clean and dry item if the process is completed. If the items are not dry after removal from the machine, the manager must be notified and the fault rectified. 
Step 7: storage
Every ward should have a well-equipped dirty utility room or sluice in close proximity to the beds in order to clean and disinfect nursing equipment.(9) To keep clean and contaminated equipment separate, the unit must be divided into two clearly recognisable zones.  
Survey
A questionnaire was sent by email to 1176 infection control professionals in hospitals of 116 countries. Thirty questions covered the following items: bedpan material, place of emptying of the content, methods of emptying, cleaning and disinfection, awareness of ISO standard for WD15883 and the frequency of validation and maintenance. The battle against C. diff infections requires special attention and one question was devoted to the existence of specific guidelines for C. diff.(10) The final questions covered the role of bedpans and WDs as sources of HAIs.
Results
The results of the questionnaire do not represent the global situation but correspond to personal observations of the author. The results give only an impression of the full picture and more study about this risk are needed for validation (see Table 1). 
There are large differences in the practices of emptying, cleaning and disinfecting bedpans. Only Norway, Sweden, Denmark, Belgium and Holland reported protocols for managing bedpans and bottles. 
The response rate to the questionnaire in the Netherlands was 59% (77 hospitals), and 238 infection control professionals from 52 countries (13%; Table 2) also participated.
The majority of hospitals in low income countries do not have WDs or macerators. Some remarkable answers include “WD use is limited to ICUs”,  “WD is located too far away and therefore we do not use it”, “the equipment stays in the room and excretions are disposed of in the bathroom; equipment is disposed of in the trash after the patient discharges” and “WDs are not maintained and are out of order”. A number of hospitals (13) did not use bedpans and urine bottles but gave all bedridden patients, without any medical indication, incontinence pants for stools and a permanent urine catheter with prophylactic antibiotics to prevent urinary tract infections.
Nurses or nursing assistants empty bedpans manually mainly in the toilet or slop hopper (65%), even if there was a WD or macerator in place. With cases of C.diff, 3–46% of the responders took specific measures. 
Often cleaning is done only by rinsing or spraying water and is not followed by disinfection. Single-use bedpans per patient per stay are used in some hospitals (8%) and other hospitals sent bedpans to a central sterile department after discharge of the patient (7%). Macerators were in place in only 14% of hospitals. However, this information is biased because this system is popular in the UK but only one colleague from the UK responded.
In Western Europe, 97% of the responders use a WD often without prior validation or regular maintenance. The international standard ISO15883 is best known in north-west Europe (76%) in contrast to the rest of the world (14–37%). It is only in the Netherlands that all hospitals use WDs (100%) and maintenance and validation showed better results in the 2010 survey compared with the 1990 survey, but they are not yet optimal. 
The majority of the responders never considered bedpans and WD as potential sources of HAIs outbreaks. In this survey, 3–21 % reported HAI and outbreaks of the following microorganisms where bedpans played a key role: C. diff, Norovirus, Pseudomonas aeruginosa, Salmonella species and Acinetobacter baumannii. These results have not been shared or published.
Discussion
There is no global consensus for bedpan management and the procedure depends on hospital habits with no regard for infection prevention. The use of catheters and incontinence pants without clinical indication to avoid using bedpans is malpractice and should be prohibited. In many countries, bedpans and urine bottles are not clean and shows signs of soiling, which is unethical practice and can be reservoirs for pathogens. Although nowadays the focus is on safe care for patients, the awareness of bedpan management risk is low.  
The use of bedpans and bottles is too often a non-spoken issue by users and administrators. Insufficient decontamination increases the risk of HAIs, which is a serious threat for patients, causing pain, infirmity and sometimes death. Spaulding’s decontamination scheme for bedpans as a non-critical patient-care item is no longer valid. Safe reprocessing of medical equipment by standardised procedures is a global challenge in terms of preventing the spread of infection to patients and staff and selecting equipment that meets the standard. Nurses and other healthcare personnel need the right tools and equipment to do their jobs effectively but this group seldom puts on any pressure for improvements. 
Conclusions
The risk of HAIs by poor bedpan handling is shown in the survey. Because of the ongoing problem of antibiotic treatment for resistamt organisms, we must focus on basic hygiene including good hand hygiene and effective cleaning, disinfection and sterilisation methods. Audits can help to focus on what personnel are actually doing. If bedpan and bottle management is manual, which is the case in many countries, there standards must be set to optimise the process. To help fight and eliminate HAIs, hospitals have to recognise any weaknesses in bedpan management and set improvements and investments within their means. Handling full bedpans must take place under the most sanitary and least offensive conditions and manual procedures must be avoided as far as possible.(10) 
Well-designed, validated and regularly maintained WDs improve patient safety, and contribute to occupational health by minimising the risk for infections and protect staff from an unpleasant task.(7)
Increasing awareness of the risk of emptying and decontaminating bedpans is a step in the right direction. The IFIC has initiated an international project to obtain more information about faeces management in hospitals.
References
  1. Health Protection Agency. Guidelines for the management of norovirus outbreaks in acute and community health and social care settings. www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317131639453 (accessed 5 March 2012)
  2. Alfa MJ, Olsen N, Buelow-Smith L. Simulated-use testing of bedpan and urinal washer disinfectors: evaluation of Clostridium difficile spore survival and cleaning efficacy. Am J Infect Control 2008;36:5–11.
  3. Spaulding EH.  Chemical disinfection of medical and surgical materials.  In: Lawrence C, Block SS (eds) Disinfection, Sterilization, and Preservation.  Philadelphia: Lea and Febiger, 1968:517–31.
  4. Knippenberg-Gordebeke, GGM, Bedpanspoelers: een vergeten probleem? 1990.
  5. Dutch Working Party Infection Prevention (WIP) Bedpanwasher, 2005 www.wip.nl.
  6. Washer-disinfectors. International Standard ISO/FDIS 15883, 2006. 
  7. Satar S. Cleaning, disinfection and sterilisation, In: Basic concepts of infection control, Chapter 12, 2nd ed, revised 2011 www.theIFIC.org
  8. Lobè C, Boothroyd LJ.Bedpan processing methods: making an informed choice. Can J Infect Control 2011;26:165–71.
  9. Bartley J, Olmsted R, Haas J. Current views of health care design and construction: Practical implications for safer, cleaner environments. Am J Infect Control 2010;.38:S1-S12.
  10. Van Knippenberg-Gordebeke GG. Dutch surveys bedpan management (1990 & 2010): progress in correct use of washer disinfectors. Presentation at the International Conference on Prevention & Infection Control (ICPIC). BMC Proceedings 2011, 5(Suppl 6):P308doi:10.1186/1753-6561-5-S6-P308.