|Year : 2015 | Volume
| Issue : 2 | Page : 243-247
Is non-woven fabric a useful method of packaging instruments for operation theatres in resource constrained settings?
GS Devadiga1, VMP Thomas2, S Shetty3, MS Setia4
1 Department of Central Sterile Supply, Dr. L H Hiranandani Hospital, Powai, Mumbai, Maharashtra, India
2 Department of Operations and Projects, Dr. L H Hiranandani Hospital, Powai, Mumbai, Maharashtra, India
3 Department of Laboratory Medicine, Dr. L H Hiranandani Hospital, Powai, Mumbai, Maharashtra, India
4 Department of Consultant Epidemiologist, Dr. L H Hiranandani Hospital, Powai, Mumbai, Maharashtra, India
|Date of Submission||18-Mar-2014|
|Date of Acceptance||26-May-2014|
|Date of Web Publication||10-Apr-2015|
M S Setia
Department of Consultant Epidemiologist, Dr. L H Hiranandani Hospital, Powai, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Studies have highlighted the advantages and disadvantages of woven and non-woven fabrics. The present study assessed the change in resterilisation proportion after introduction of non-woven fabric for packaging of instruments and to evaluate the cost-effectiveness of non-woven fabrics compared with woven fabrics. Materials and Methods: The present study is a secondary data analysis of resterilisation data collected from November 2009 to August 2013. We calculated the proportions (and their 95% confidence intervals) of resterilisation done every month. The proportion over time was compared using a Chi-square test for trend. We used linear regression analysis to adjust for the number of surgeries performed every month. We also compared the cost of woven and non-woven fabrics. Results: Of the total 117,335 surgical packets prepared during the study period, 1900 were resterilised; thus, the overall proportion was 1.62% (95% CI: 1.55% to 1.69%). The resterilisation proportion was 8.95% (95% CI: 7.73% to 10.17%) in November 2009 and was 0.38% (95% CI: 0.16% to 0.62%) in August 2013 (P < 0.001). After adjusting for the total number of surgeries conducted every month, we found that the number of packets resterilised reduced every month (per month reduction: -1.97, 95% CI: -2.76 to -1.18). The total cost (initial preparation and resterilisation) for 100 units of woven fabric is INR 6359.41 per month (confidence limit estimates: 6228.20 to 6430.62) and for non-woven fabric was INR 6208.50 (confidence limit estimate: INR 6194.90 to 6223.35) (P < 0.01). Conclusions: The introduction of non-woven spunbond-meltblown-spunbond fabrics did reduce the proportion of resterilisation of packaged instruments. The decline was sharp and sustained over time, even after accounting for the change in the number of procedures. Furthermore, though the switch from woven to non-woven fabric was cost-effective in our situation, it may not be directly translated to other scenarios.
Keywords: Cost-effectiveness, non-woven fabric, sterilisation
|How to cite this article:|
Devadiga G S, Thomas V, Shetty S, Setia M S. Is non-woven fabric a useful method of packaging instruments for operation theatres in resource constrained settings?. Indian J Med Microbiol 2015;33:243-7
|How to cite this URL:|
Devadiga G S, Thomas V, Shetty S, Setia M S. Is non-woven fabric a useful method of packaging instruments for operation theatres in resource constrained settings?. Indian J Med Microbiol [serial online] 2015 [cited 2020 Apr 4];33:243-7. Available from: http://www.ijmm.org/text.asp?2015/33/2/243/154862
| ~ Introduction|| |
Sterilisation is an important component of hospital management; this can be achieved by properly sterilising the instruments and covering them so that they remain sterile till they come in contact with the patients. This process - packaging - is important to maintain the sterility of the medical devices and instruments.  Some of the important characteristics of the packaging materials are: Strong and durable; barrier for microorganisms; efficient to use; non-toxic; safe and easy to open; and a good shelf life. Initially, the main packaging material was woven fabric usually made of cotton or linen.  There are other packaging materials such as papers, plastic films, combination of paper and plastic, and rigid packaging systems. Apart from woven fabrics, non-woven fabrics are also used for packaging the sterilised instruments.  One such material is the spunbond-meltblown-spunbond (SMS) fabric. Since the woven fabrics are laundered prior to every use, they may potentially lose some barrier properties; thus, the shelf life for instruments wrapped with this fabric is kept at a minimal level of seven days. Non-woven SMS fabrics on the other hand, usually, have a longer shelf life - as high as three months.  Following, the expiry of shelf life, the packed instruments have to resterilised and repacked.
Studies and reports have highlighted the advantages and disadvantages of woven and non-woven fabrics. , The three main points of concern are: Cost-effectiveness; role in infection prevention; and environmental issues. , The reusable and disposable nature of the woven and non-woven fabrics may play a role in affecting these three aspects of packaging fabrics. Studies have shown that disposable products may be cost-effective and may have lower risk of post-procedural infection. ,,,, Other authors have shown that bacterial blockade is similar in both types of fabrics.  However, reusable fabrics may be environment-friendly.  Thus, there may be advantages and disadvantages of either of the packaging material.
Though, the cost-effectiveness of woven and non-woven fabrics have been routinely done in most parts of the world, often with contradictory opinions, such an evaluation has not been adequately done in India. Thus, the present study was conducted to assess the change in resterilisation proportion after introduction of non-woven SMS fabric for packing of instruments and to evaluate the cost-effectiveness of non-woven fabrics compared with woven fabrics.
| ~ Materials and Methods|| |
The present study is a secondary data analysis (retrospective analysis) of resterilisation data collected from November 2009 to August 2013.
The study was conducted at the Central Sterile Supply Department (CSSD) of the Dr. LH Hiranandani Hospital, a tertiary care centre in Suburban Mumbai. The department is responsible for provision of sterile instruments and linen packets during surgical procedures. The department used woven fabric for wrapping the sterile instruments till December 2009 and subsequently changed to non-woven fabric (SMS) for wrapping them.
We collected data on the number of packets prepared, resterilised, and number of surgeries every month from November 2009 till August 2013. The data were collected for individual departments (general surgery, obstetrics and gynaecology, orthopaedics, neurosurgery, otorhinolaryngology, ophthalmology, cardiac surgery, and minimally invasive surgery [laparoscopy]).
Data were entered into Microsoft Excel (© MS Office) and converted to Stata Version 11.2 (© StataCorp, College Station, Texas, US) for analysis. We calculated the proportions of resterilisation done every month and their 95% confidence intervals. The proportion over time was compared using a Chi-square test for trend. The difference between the estimates and the confidence intervals was estimated using the methods described by Altman and Bland.  We used linear regression analysis to adjust for the total number of surgeries performed every month.
We also calculated the cost of woven and non-woven fabrics per usage. For the woven fabric, we used the cost for total area (INR 264.00 for 2.09 m 2 and INR 65.00 for 0.84 m 2 ), average life span (40 cycles), and cost of washing the fabric per cycle (INR 9.00 per piece). The usage of these two sizes of fabric per month is in a ratio of 1:4. For the non-woven fabric, we used the cost or total area (INR 17.85 for 0.81 m 2 and INR 11.00 for 0.56 m 2 ). The ratio of usage was similar as for the woven fabric. We also performed multiple iterations to calculate the total cost (initial preparation and resterilisation) for various proportions of resterilisation of woven and non-woven fabric. The iterations were used to calculate the cost differences between the two types of fabric.
The study was approved by the Ethics Committee of Dr. LH Hiranandani Hospital for secondary data analysis.
| ~ Results|| |
Of the total 117,335 surgical packets prepared during the study period, 1,900 were resterilised; thus the overall proportion was 1.62% (95% CI: 1.55% to 1.69%). The resterilisation proportion was 8.95% (95% CI: 7.73% to 10.17%) in November 2009 and was 4.12% (95% CI: 3.32% to 4.92%) in January 2010. There was a gradual reduction in the proportion over the study period [Figure 1]. The proportion had reduced to 1.78% (95% CI: 1.26% to 2.31%) by January 2012 and it was as low as 0.38% (95% CI: 0.16% to 0.62%) in August 2013; the trend in reduction of resterilisation over time was statistically significant (Chi-square for trend, P < 0.001). The proportion of resterilisation for individual surgical categories did not show any consistent pattern. Even after adjusting for the total number of surgeries conducted every month, we found that the number of packets resterilised reduced every month (per month reduction: -1.97, 95% CI: -2.76 to -1.18).
|Figure 1: Figure showing the reduction in resterilisation at baseline and after introduction of non-woven fabric, November 2009 - August 2013, Mumbai|
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The total cost of woven fabric for the entire 40 cycle use for woven fabric of 2.09 m 2 is INR 634 (per unit price*number of cycles of reuse* cost of washing per fabric) and for size 0.84 m 2 is INR 425. The average cost of both these sizes of woven fabric is INR 1167 ([one 2.09 m 2 + four 0.84 m 2 ]/2). The cost of per unit usage of woven fabric is INR 15.85 for 2.09 m 2 and INR 10.63 for 0.84 m 2 . The total cost of non-woven fabric for 40 uses for size 0.81 m 2 will be INR 714 and for size 0.56 m 2 will be INR 440. The average cost of both these sizes of non-woven fabric is INR 1237.
The resterilisation cost for 100 units of woven fabric (each composed of 1 unit of 2.09 m 2 and 4 units of 0.84 m 2 ), using the estimates from baseline will be INR 522.41 per month (confidence limit estimate costs: INR 451.20 to 593.62). The total cost (initial preparation and resterilisation) for 100 units of woven fabric is INR 6359.41 per month (confidence limit estimates: 6228.20 to 6430.62). The resterilisation costs for 100 units of non-woven fabric, using January 2012 estimates will be INR 110.09 (confidence limit estimates: INR 77.93 to 142.87); the resterilisation cost was significantly lower when compared with woven fabric (P < 0.01). The total cost at this estimate will be INR 6295.09 (confidence limit estimates: INR 6262.93 to 6327.87), and this difference was not statistically significant (P = 0.24). However, by August 2013 the estimated resterilisation cost had reduced to INR 23.50 per month (confidence limit estimate costs: INR 9.90 to 38.35); the difference between costs of woven and non-woven fabric per month was statistically significant (P < 0.01). Furthermore, the total cost was estimated to be INR 6208.50 (confidence limit estimate costs: INR 6194.90 to 6223.35); the differences between the total costs of two fabrics was statistically significant (P = 0.004).
We have presented total costs for various proportions of resterilisation among woven and non-woven fabric [Figure 2]. As seen, if the resterilisation proportion for woven fabric is up to 6.4%, the total costs will be lower compared with non-woven fabric even if the resterilisation proportion for the non-woven fabric is as low as 0.5%. Similarly, if the resterilisation proportion in the non-woven fabric is as high as 5%, the total costs will be higher in this group compared with the woven fabric even if the resterilisation proportion in the woven fabric group is as high as 11%. The various cut-offs for resterilisation proportions of woven and non-woven fabric at which point the total costs for non-woven is lower compared with woven are shown in [Table 1].
|Figure 2: Graph showing multiple iterations for total cost (initial preparation and resterilisation) of woven and non-woven fabrica, a = The diagonal line represents the total cost of woven fabric at various retserilisation proportions (0.1% to 11%); the multiple horizontal lines represent the total cost of non-woven fabric at 10 different resterilisation proportions (0.5% to 5% in increments of 0.5%) - the lowest horizontal line is 0.5% and it increases by 0.5% subsequently and highest horizontal line is 5%|
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|Table 1: Multiple cut - offs of resterilisation proportion of woven and non - woven fabric groups at which point the total cost (initial preparation and resterilisation) in the woven group is less compared with non - woven fabric group |
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| ~ Discussion|| |
After the use of non-woven fabric, the resterilisation proportion of surgical kits reduced considerably - from as high as 9% to less than 0.5% over a period of four years. Even after adjusting for the total number of surgeries conducted every month, we found that there was significant reduction in resterilisation after the introduction of non-woven fabric. We also found that even though the initial purchase costs were higher for non-woven fabric compared with woven fabric, the total costs (including resterilisation costs) were lower for the former compared with the latter in our hospital.
Cost-efficacy and infection control are important considerations while comparing woven and non-woven material. The woven material is reusable and can be laundered to be used again - usually up to 40 times. This may potentially reduce the costs of repeat purchase. However, due to the long shelf life of non-woven fabric, there was an overall reduction of costs - as seen in our setting. Use of disposable products has been shown to be cost beneficial by others as well. , For instance, Lim and colleagues found that disposable forceps was a cost-effective option compared with reusable forceps.  Similarly Moylan and co-workers reported that disposable gowns and drapes were most cost-effective compared with regular cotton fabrics in various hospital settings. , However, not all authors agree with this proposition. Indeed, McGain and colleagues have highlighted that use of single use drug trays cannot be justified either financially or environmentally.  Other authors , have suggested that reusable products are more environment-friendly; they reduce medical waste and the cost associated with waste disposal. Another important feature, however, of the using disposable material is the reduction in the risk of infection. , Though many studies have indicated a higher risk of nosocomial infections with reusable cloth fabrics, some have not found this to be the case; thus, there are conflicting reports on reduction. ,,,, Nonetheless, reduction in infections and its use in tropical climates are other important aspects of non-woven fabric apart from the cost-effectiveness.
An important point, however as seen in our analysis, is that non-woven fabrics are not always cost-effective. It may potentially depend on the rate of resterilisation in the health care setting. As seen in the results, on one hand, if the initial resterilisation proportion itself is very low, then a switch to the non-woven fabric may not be cost-effective. However, on the other hand even after a switch to non-woven fabric, if the resterilisation proportion remains high, then again the process may not be cost effective. Thus, the cost-effectiveness will depend on the initial resterilisation proportion while using woven fabric and the reduction in the same after switching over to the non-woven fabric. This reduction in proportion not only depends on the shelf life of the sterile instruments in non-woven fabric but also on the initial number of units prepared and the number of surgeries conducted. Thus, it is possible that the cost advantage of the non-woven fabric may not be applicable to all scenarios. Nonetheless, given the long shelf life of the non-woven fabric, it is likely that the resterilisation rates will drop substantially (as was seen in our case) and potentially the switch from woven to non-woven fabric will be cost-efficient in the long run.
The study was not without its limitations. For instance, it is generally recommended that in the cost-effectiveness analysis, there should be additional component of loss of reusable material due to damage; this proportion should be about 2%.  However, it has been highlighted that after accounting for damage at 2% loss, a reusable material that has been manufactured for 80 uses will end up being used for 41 times;  thus, we have accounted for the loss by calculating reuse for 40 times in our analysis. Furthermore, we also did not perform a microbiological analysis of the packets; thus, we did not have information on the proportion of infected packets in both these groups or the barrier role of these two types of fabrics. However, our main focus to ascertain the role of non-woven fabric in changing the resterilisation percentage and the cost-effectiveness of the same.
Finally, as seen from our study, the introduction of non-woven SMS fabrics did reduce the proportion of resterilisation of packaged instruments. The decline was sharp and sustained over time, even after accounting for the change in the number of procedures. Furthermore, though the switch from woven to non-woven fabric was cost-effective in our situation, it may not be directly translated to other scenarios. As shown, a critical proportion of resterilisation may be necessary before a switch to non-woven SMS fabric may be cost-effective. Thus, it may be important to have baseline resterilisation proportion for individual health care settings to make an informed decision to consider a switch to a non-woven SMS fabric for cost-effectiveness.
| ~ Acknowledgements|| |
We would like to acknowledge Dr. S Chatterjee (CEO) for support and suggestions.
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[Figure 1], [Figure 2]