Abstract
Aim. This review article discussed the cost-effectiveness of disposable suction bottles in Iran. Background. Healthcare-associated infections (HAIs) cause mortality and morbidity in patients, especially in the intensive care unit (ICU). Different methods and instructions exist to control HAI, which is an important and fundamental problem related to suction.
Method. Searching out for articles through databases including Science Direct, PubMed, Cochrane, Medline, SID, Scopus, CINAHL, OVID, Iran Doc, and Magiran using the keywords “disposable suction”, “hospital infection”, “waste management” and their English equivalent were conducted. Articles that were published between 2000 and 2022 and were more related to the main focus of the research topic were selected. The inclusion criteria included their publication in reputable scientific journals, publication in Farsi or English, and access to the full text of the article. Exclusion criteria included publishing articles in weak and invalid journals.
Findings. Disposable suction bottles were evaluated in five domains including hospital infection control and prevention, water consumption management, ease of use, waste management, and cost-effectiveness.
Conclusion. Considering the lack of manpower for disinfecting disposable suction bottles, the costs of disinfectant solutions and their improper use in diluting them, and the management of wastewater from used solutions and emptying suction canisters; disposable suction bottles have priority over reusable suction bottles in Iran.
Keywords: Suction, Healthcare-associated Infections, Disposable Suction Bottle, Cost-effectiveness
Introduction
Healthcare-associated infections (HAIs) are the leading preventable cause of morbidity and mortality in hospitalized patients. According to the Centers for Disease Control and Prevention (CDC), complications or secondary infections related to device placement or surgery are recognized as healthcare-associated infections. Specifically, the CDC monitors surgical site infections, central line-associated bloodstream infections, catheter-associated urinary tract infections, and ventilator-associated pneumonia (Boothe & Keys, 2012). An endotracheal tube holder increases the risk of ventilator-associated pneumonia as it disrupts patients’ natural airway defenses. For instance, a reduced cough reflex allows microorganisms to access the lower respiratory tract. Continuous inhalation of small droplets from the mouth and throat is the primary mechanism of ventilator-associated pneumonia (Waters et al., 2012). Primary pneumonia usually occurs due to bacterial colonization from the nose and throat, but there is a weak association between late-onset pneumonia and microaspiration. To reduce continuous aspiration of secretions around the endotracheal tube cuff, intermittent or continuous suctioning to remove oral and throat secretions is recommended (Yazdannik et al., 2012; Pagotto et al., 2012; Dezfulian et al., 2012). Hospital-acquired pneumonia is a common complication in patients admitted to intensive care units (ICU). Internal suctioning of the endotracheal tube to clear airways of secretions in mechanically ventilated patients is used. Proper suctioning technique is of paramount importance in preventing ventilator-associated pneumonia (Alipour et al., 2012).
Endotracheal suctioning is one of the most common invasive methods used by critical care nurses to remove accumulated respiratory secretions, ensure airway patency for adequate ventilation and oxygenation, and prevent atelectasis in patients with endotracheal tubes. Suctioning involves clearing secretions using negative pressure through an appropriately sized suction catheter. This procedure may be performed by nurses and the healthcare team in an emergency situation or as part of patient care (Dexter & Scott, 2012). The goal of oral suctioning is to maintain the patient’s oral moisture and health or remove blood and vomitus in an emergency situation, as well as to remove respiratory secretions in patients unable to effectively cough them out. The patient may be fully conscious or experiencing varying degrees of decreased consciousness. With suctioning, secretions are cleared from the airways of these patients, secondary atelectasis and airway obstruction are prevented, and effective and sufficient oxygenation is achieved (Schalk & colleagues, 2011). Complications of suctioning include reduced lung compliance, atelectasis, hypoxia, and hypercapnia, decreased or increased blood pressure, cardiac dysrhythmias, tissue damage to the trachea and bronchial mucosa, bronchospasm, increased microbial colonization in the lower airways, and changes in cerebral blood flow, which may occur depending on the patient’s condition if performed improperly (Van der Loo & colleagues, 2012; Maguire & colleagues, 2012). In the ten-module program for controlling and preventing pneumonia infections in the intensive care unit (ICU), the procedure for suctioning and specimen collection is described (Weinstein et al., 2012).
According to the latest report from the Ministry of Health of IRAN, out of approximately 9.6 million hospitalized patients, about 12,800 individuals (0.75%) were affected by healthcare-associated infections, with 15.65% of them resulting in fatalities. Ventilator-associated pneumonia was the most common device-related infection, occurring more frequently every 1000 days of mechanical ventilation, and had the highest mortality rate (43.08%) (Masoudifar et al., 2022). However, according to the World Health Organization’s report, the rate of hospital-acquired infections in Iran ranges from 8 to 10%, with more than 25% estimated in intensive care units (Kalantari-Zarrabad et al., 2014). Various factors contribute to the occurrence of hospital-acquired infections, with suctioning being one of them (Rodriguez-Salas et al., 2017; Mosadeghgharad et al., 2021). In a study conducted in Iran, suctioning, endotracheal tubes, urinary catheters, surgical history, and ventilators were reported as the most common factors in hospital-acquired infections in Iranian hospitals (Rahmanian et al., 2017). In a study investigating the occurrence and prevalence of hospital-acquired infections in neonatal intensive care units in Iran, researchers found a significant statistical association between invasive procedures (such as suctioning and intubation) and pneumonia (Hosseini et al., 2014).
Based on the author’s clinical experience, suctioning issues are considered one of the key challenges in hospital infection control and patient care. In this review article, the cost-effectiveness of Disposable Suction bottles in Iran has been discussed and examined.
Methods
Articles were searched through databases including Scopus, SID, Medline, Cochrane, PubMed, Science Direct, Iran Doc, OVID, CINAHL, and Magiran using the keywords ” Disposable Suction Bottle,” “hospital-acquired infection,” and “waste management,” along with their English equivalents. Articles published between 2000 and 2022 were included if they were deemed relevant to the main focus of the research. Inclusion criteria comprised publication in reputable scientific journals, availability in Persian or English, and accessibility to the full-text article. Exclusion criteria included publication in weak and unreliable journals. After reviewing the titles and abstracts, and in some cases, full-text examination, articles meeting the research objectives were selected for further review and analysis.
Findings and Discussion
Disposable Suction Bottles were evaluated in five dimensions hospital infection control and prevention, water consumption management, ease of use, waste management, and cost-effectiveness. The study by Kaye et al. (2010), titled “Suction Regulators: A Potential Vehicle for Nosocomial Pathogens,” showed that sampling from suction regulators in 37% of cases was colonized with microorganisms. A rotational suction model demonstrated that pathogens could spread throughout the suction circuit (retrograde and antegrade) and colonize the stomach. In a study aimed at investigating “The Effects of Disposable Suction Bottle on COVID-19 Infection and Nurse Encounters during Endotracheal Suctioning,” it was shown that the use of Disposable Suction Bottle for hospitalized patients resulted in reduced exposure of healthcare workers to COVID-19 and decreased incidence of healthcare worker infections after using Disposable Suction Bottle. It was also reported that Disposable Suction bottles were more effective than glass bottles (Hongza et al., 2022).
The suction device and its attachments, along with the suctioning technique, play a fundamental role in reducing the risk of hospital-acquired infections. Infection prevention during suctioning focuses on aseptic technique, hand hygiene, and disinfection and sterilization of equipment when necessary (Mohabatra, 2017; Haghighani, 2015). In a study on 122 wet swab samples from reusable items, it was found that 29.5% of the samples contained pathogens. Additionally, 80 wet swab samples were taken from sterile disposable products, and all were negative for pathogens. This result demonstrated that the level of protection is higher when using disposable products, suggesting that reusable materials should be replaced with disposable materials to reduce hospital-acquired infections, highlighting the importance of disposable medical materials and tools in preventing hospital-acquired infections (Esbougt-Milosevic et al., 2000). According to the World Health Organization guidelines (2020), materials exposed to patients with COVID-19 pneumonia should not be reused. Following a controlled randomized trial conducted in two hospital wards to replace reusable suction bottles and monitor admission outcomes in the intensive care unit monthly, the use of Disposable Suction Bottle was recommended. In the intensive care unit, one of the sources of cross-infection is the changing of equipment parts from one patient to another (Shawver-Zack et al., 2021).
The study by Solle et al. (2002), aimed at investigating “Bacterial Growth in Oral Secretions and Suction Equipment of Endotracheally Intubated Patients,” demonstrated that after 24 hours, all subjects had potential pathogens in their mouths, and 67% of sputum cultures were positive for pathogens. Suction devices were colonized with many similar pathogens present in the mouth.
Almost all suction devices (94%) were colonized within 24 hours. Most potential pathogens were Gram-positive bacteria. Gram-negative bacteria and antibiotic-resistant organisms were also present in several samples. The presence of pathogens in oral and sputum samples in most patients confirms the occurrence of the micro aspiration of secretions. Colonization is a risk factor for ventilator-associated pneumonia. Equipment used for oral and endotracheal suctioning becomes colonized with potential pathogens within 24 hours (Solle et al., 2002). In a study by Narunat et al. (2020) in Thailand comparing the effect of two types of suction with two clean and sterile methods, it was found that the clean group had a positive bacterial growth rate of 64.2% and the sterile group had a positive bacterial growth rate of 57%, and this difference was not statistically significant. The rate of bacterial contamination from endotracheal suctioning with the clean and sterile methods was similar, and the likelihood of contamination in the clean group was higher than in the sterile group, all of which can be controlled using disposable suction bags to prevent hospital-acquired infections.
Water management was one of the extracted axes in this study. Reducing water consumption and disinfection costs is possible by using disposable suction bottles. For reusable items, it must be ensured that they are properly cleaned, disinfected, washed, and drained to be usable for another patient. Using disposable items requires less water consumption. The only potential increase in water consumption is the demand for additional water needed to clean reusable products. This situation is especially critical for areas where water is a scarce resource and for future water scarcity scenarios, especially during the summer months, which are increasing globally (Kyle et al., 2023).
Waste management was another evaluative aspect of this study. Interest in examining the environmental effects of healthcare practices is increasing (Griffiths et al., 2008; McKeown et al., 2010). Matisse et al. (2023) suggest that replacing disposable products with reusable ones may reduce the environmental impacts of healthcare practices. Switching to reusable healthcare products is likely to reduce environmental impacts other than water consumption, but the magnitude of the impact varies among different product categories (Kyle et al., 2023; Dettenkofer et al., 1999). The ease of use of disposable suction canisters is one of the advantages of this product because they are discarded after use, unlike reusable bottles that require human resources, disinfectant solution, and other items.
Financial management is one of the recent challenges of hospitals. Disposable suction bottles need to be used separately for each patient. A study conducted to examine the cost-effectiveness of controlling and preventing hospital-acquired infections through disposable suction emphasized examining all aspects (Kolff, 2001). Since these bottles are disposable, there is no need for human resources for cleaning, disinfection, and disposal, especially in current conditions where there is a shortage of manpower in healthcare facilities (Noubakht et al., 2018). On the other hand, there is no need for intermediate-level disinfectant solutions used for reusable bottles to disinfect disposable bottles, thus eliminating the need for disinfectant solutions (Moscarella, 2007). Disposable rigid bottles require minimal additional hardware, whereas reusable suction bottles require liners (Duan et al., 2020; Asfaw et al., 2021).
Conclusion
Based on the findings of this study, disposable suction bottles should be purchased and used separately for each patient. However, in Iran, due to the shortage of manpower for disinfecting reusable suction canisters, the costs of disinfectant solutions, and improper use due to difficulties in diluting them, as well as challenges in managing the disposal of wastewater from the used solutions and the discharge of suction canisters, disposable suction canisters are preferred over reusable ones. Therefore, the use of disposable suction bottles is cost-effective in healthcare facilities.
Resources
Rahmanian, Vahid; Shakery, Hashemallah; Shakery, Massihallah; Rahmanian, Karamatallah; Rahimi, Masoumeh. (2017). Epidemiology of Hospital-Acquired Infections in Hospitalized Patients in Jahrom City Hospitals in 1395. Pars Journal of Medical Sciences, 15(1), 57-66.
Masdagh Rad, Ali Mohammad; Afshari, Mahnaz; Esfahani, Parvaneh. (2020). Prevalence of Hospital-Acquired Infections in Iranian Hospitals: A Systematic Review and Meta-Analysis. Iranian Journal of Epidemiology, 16(4), 352-362.
Alipour N, Manouchehrian N, Sanatkar M, Anvari HMP, Jahromi MSS. Evaluation of the effect of open and closed tracheal suction on the incidence of ventilator associated pneumonia in patients admitted in the intensive care unit. Archives of Anesthesiology and Critical Care.2016; 2: 193-196.
Alkubati SA, Al-Sayaghi KM, Alrubaiee GG, Hamid MA, Saleh KA, Al-Qalah T, et al. (2022). Adherence of critical care nurses to endotracheal suctioning guidelines: a cross-sectional study. BMC nursing. 2022;21: 312.
Asfaw SH, Galway U, Hata T, Moyle J, Gordon IO. Surgery, anesthesia, and pathology: a practical primer on greening the delivery of surgical care. The Journal of Climate Change and Health. 2021; 4: 100076.
Boev C & Kiss E. Hospital-acquired infections: current trends and prevention. Critical Care Nursing Clinics. 2017; 29: 51-65.
CREAMER, E. & SMYTH, E. 1996. Suction apparatus and the suctioning procedure: reducing the infection risks. Journal of hospital infection, 34, 1-9.
DETTENKOFER, M., GRIESSHAMMER, R., SCHERRER, M. & DASCHNER, F. 1999. Life-cycle
assessment of single-use versus reusable surgical drapes (cellulose/polyethylene-mixed cotton system).
Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen, 70, 485-91; discussion 491.
Dexter AM, Scott JB. (2019). Airway management and ventilator-associated events. Respiratory Care, 64, 986-993.
Dezfulian C, Shojania K, Collard H R, Kim H M, Matthay M A, Saint S. (2005). Subglottic secretion drainage for preventing ventilator-associated pneumonia: a meta-analysis. The American journal of medicine, 118, 11-18.
Duane B, Ashley P, Ramasubbu D, Fennell-Wells A, Maloney B, McKerlie T. 2022. A review of HTM 01- 05 through an environmentally sustainable lens. British Dental Journal, 233, 343-350.
Griffiths J, Hill A, Spiby J, Stott R Ten practical actions for doctors to combat climate change. BMJ 2008.336; 150:1507.
Haghighat S, Yazdannik A. The practice of intensive care nurses using the closed suctioning system: An observational study. Iran J Nurs Midwifery Res. 2015;20(5):619-25.
Hosseini, M. B., Abdinia, B., Ahangarzadeh Rezaee, M., & Abdoli oskouie, S. (2014). The Study of Nosocomial Infections in Neonatal Intensive Care Unit, A prospective study in Northwest Iran. International Journal of Pediatrics, 2(3.2), 25-33.
eal suctioning COVID-19 infection and exposures of nurses. Journal of Shifa Tameer-e-Millat University,
5, 11-14.
Kalantarzadeh M, Mohammadnejad E, Ehsani S R, Tamizi Z. Knowledge and Practice of Nurses About the Control and Prevention of Nosocomial Infections in Emergency Departments. Arch Clin Infect Dis. 2014;9(4):e18278.
Kaye K, Marchaim D, Smialowicz C, Bentley L. 2010. Suction regulators: a potential vector for hospital- acquired pathogens. Infection Control & Hospital Epidemiology. 2010; 31: 772-774.
Keil M, Viere T, Helms K & Rogowski W. The impact of switching from single-use to reusable healthcare products: a transparency checklist and systematic review of life-cycle assessments. European Journal of Public Health. 2022; 33: 56-63.
Kollef, M.H. 2001. Is Prevention of Ventilator-Associated Pneumonia Cost Effective? Ventilator- Associated Pneumonia. Springer.
Maggiore SM, Lellouche F, Pignataro C, Girou E, Maitre B, Richard JC, Lemaire F, et al. 2013. Decreasing the adverse effects of endotracheal suctioning during mechanical ventilation by changing practice. Respiratory care. 2013; 58: 1588-1597
Masoudifar M, Gouya MM, Pezeshki Z, Eshrati B, Afhami S, Farzami MR, Seifi A. Health care-associated infections, including device-associated infections, and antimicrobial resistance in Iran: The national update for 2018. J Prev Med Hyg. 2022;62(4):E943-E949. d
McGain F, McAlister S, McGavin A, Story D. The financial and environmental costs of reusable and single
-use plastic anaesthetic drug trays. Anaesthesia and intensive care. 2010;38: 538-544. Mohapatra S. Sterilization and Disinfection. Essentials of Neuroanesthesia. 2017:929–44.
Muscarella LF. 2007. Prevention of disease transmission during flexible laryngoscopy. American journal of infection control. 2007; 35: 536-544.
Narunart K, Wasinwong W, Siripruekpong S, Chantarokorn A, Kosem R (2020). Bacterial Con-tamination from Intraoperative Endotracheal Suctioning in Songklanagarind Hospital. Int J Respir Pulm Med, 7, 130. Nobakht S, Shirdel A, Molavi‐Taleghani Y, Doustmohammadi MM, Sheikhbardsiri H.. 2018. Human resources for health: A narrative review of adequacy and distribution of clinical and nonclinical human resources in hospitals of Iran. The International journal of health planning and management, 33, 560-572. Pagotto IM, Oliveira LRdC, Araújo FC, Carvalho NAAd, Chiavone P. 2008. Comparison between open and closed suction systems: a systematic review. Revista Brasileira de terapia intensiva, 20, 331-338.
Rodriguez-Acelas AL, de Abreu Almeida M, Engelman B, Canon-Montanez W. Risk factors for health care–associated infection in hospitalized adults: systematic review and metaanalysis. American Journal of Infection Control. 2017; 45: e149-56.
Sbutega-Milosevic G, Slepĕvić V, Marmut Z, Bujko M. 2000. Importance of disposable medical materials and instruments in the prevention of intrahospital infections. Vojnosanitetski Pregled, 57, 55-58.
Schalk R, Meininger D, Ruesseler M Oberndörfer D, Walcher F, Zacharowski K, et al. 2011. Emergency airway management in trauma patients using laryngeal tube suction. Prehospital Emergency Care, 15, 347
-350.
Schwierzeck V, König JC, Kühn J, Mellmann A, Correa-Martínez CL, Omran H, et al 2021. First reported nosocomial outbreak of severe acute respiratory syndrome coronavirus 2 in a pediatric dialysis unit. Clinical Infectious Diseases, 72, 265-270.
Sole ML, Poalillo FE, Byers JF, Ludy JE. 2002. Bacterial growth in secretions and on suctioning equipment of orally intubated patients: a pilot study. American Journal of Critical Care, 11, 141-149.
Van de Leur JP, Zwaveling JH, Loef BG, Van der Schans CP. 2003. Endotracheal suctioning versus minimally invasive airway suctioning in intubated patients: a prospective randomised controlled trial. Intensive care medicine, 29, 426-432.
Waters C, Wiener RC, Motlagh HM. 2018. Ex vivo evaluation of secretion-clearing device in reducing
airway resistance within endotracheal tubes. Critical Care Research and Practice, 2018.
Weinstein RA, Bonten MJ, Kollef MH, Hall JB. 2004. Risk factors for ventilator-associated pneumonia: from epidemiology to patient management. Clinical Infectious Diseases, 38, 1141-1149.
WHO 2021. WHO Coronavirus (COVID-19) Dashboard: World Health Organization. WHO.
Yazdannik AR, Haghighat S, Saghaei M, Eghbali M. Comparing two levels of closed system suction pressure in ICU patients: Evaluating the relative safety of higher values of suction pressure. Iran J Nurs Midwifery Res. 2013;18(2):117-22
