Partnering for Autoclave Optimization - Surgical Sanitization in Low Resource Settings

As with any innovation project collaboration is central to success. When it came to optimizing MSF autoclaves, a core part of MSF Field operations, this realisation was put into action resulting in close partnership with various MSF operational centres, health system actors, industry and academia. MSF know a lot - but we by no means know it all. 

With MSF surgical activity increasing in complexity, from tools to processes, the demand for both more effective but also less resource intensive autoclaves has also grown in relevance in recent years. This awareness of the need for autoclave systems to be less water and energy intensive per cycle, to be more time-efficient, and to also be robust and easy to use and maintain in situations where technical support and training is lacking, ultimately motivated the launch of the SIU Autoclave Innovation Case. 

In an initial redesign with the support of a researcher at the University of Delft found that it was possible to iterate the traditional autoclave to achieve 75% less water usage, 23 - 38% less time for effective sterilization and 30-50% less energy consumption during a sterilization cycle. This made it clear that this project if successful could have substantial impact on health outcomes, particularly for therapeutic areas such as orthopaedics that require the highest quality sterilization. 

Beyond the advantages regarding time and resource efficiency, a significant outcome of the Autoclave project is the improved understanding of sterilization quality. Designing a machine that can promise the highest level of sterilization was obviously important, however beyond that this innovation project has also allowed the MSF Operational Centre in Brussels to more thoroughly assess its own protocols when it comes to sterilization.

We connected with Case Leader ANDREAS LARSSON to gain a further insight into the progression of the Autoclave case. Read on to learn more about field testing in Haiti, collaborating with sterilization experts and transferring learnings in humanitarian health innovation: 

How did you come to lead the autoclave case with the SIU? 

“After three years with a 600 km commute, I was looking for new job opportunities closer to home. Just by coincidence I came across the SIU job posting about a short-term position as case manager for the autoclave project. The previous case manager was about to start another job, so the SIU wanted to bring in a new case manager who could both move the autoclave case into the next phase and also contribute to other cases in the portfolio. It was a perfect match for me since I was looking for a part-time position that I could combine with innovation consulting.”

Why is the autoclave case important? What challenges is this case tackling?

“Autoclaves are critical in making sure that surgical procedures can be carried out with minimal risk of infection. Many medical devices are reusable and must be sterilized between each usage, normally using high-pressure saturated steam. In an MSF context, these sterilizer machines are normally used in areas where it is extremely difficult to get access to new equipment, replacement parts, or technicians with the necessary qualifications. Hospital staff often lack the required training to operate advanced equipment, and we also need to take into account that water and energy are scarce resources. 

This case was an initiative that aimed to explore a new autoclave concept that could provide the highest possible sterilization quality, use less water and energy per cycle, be more time-efficient, and be robust and easy to use and maintain in situations where technical support and training is lacking.”

Autoclaves are critical in making sure that surgical procedures can be carried out with minimal risk of infection.

Briefly walk us through the case progression and key milestones in the case time line. 

“The case started in the end of 2013 through discussions with MSF OCB’s biomedical referent on problems with the existing autoclaves used in the field, including heater element breakdowns, cumbersome vertical loading, gas requiring constant monitoring, complex valve system, etcetera. 

During the first half of 2014, the existing autoclaves where analyzed to get a better understanding of needs and requirements of a range of stakeholders, including biomedical referents and infection control referents at MSF Operational Centers, and end-users and other stakeholders at MSF hospitals in Afghanistan, Haiti, Pakistan and Kenya. In parallel, a thesis project at TU Delft explored new autoclave concepts, and Lund University contributed with an analysis of potential reasons for the failing heater elements in existing autoclaves. When I started working with the case, we finalized the register of needs and requirements, after which we involved a manufacturer to turn these needs and requirements into functional specifications. 

It took us roughly a year to do detail design and manufacturing for the first prototype that was tested in the manufacturer’s facilities outside of Paris in September of 2015. During the first half of 2016, we tested two iterations of prototypes at MSF’s training and innovation centre in Brussels, Espace Bruno Corbé.

The machine actually failed the first test, which led us to redesign the sterilization process together with a sterilization expert and the manufacturing company. The next version of the prototype autoclave was installed in an MSF hospital in Haiti in September of 2016 for the start of the field-testing phase.”

The machine actually failed the first test, which led us to redesign the sterilization process together with a sterilization expert and the manufacturing company. The next version of the prototype autoclave was installed in an MSF hospital in Haiti in September of 2016…

What is the current status of the case?

“Field-testing concluded in end of 2017. Overall, the device has performed quite well during its short lifespan. The users were satisfied as it not only performed correct sterilization of hollow instruments and surgical drill kits, but also because the autoclave was usually working faster and since they did not have to open/close valves, they could concentrate on packing the instruments. 

Because the prototype releases less heat in the room, the working conditions improved compared to when they were using four other autoclave models. In total, the autoclave performed over 3000 cycles the first year and downtime was less than 6%.”

What were the greatest learnings you gained through the case development that may support future humanitarian innovations inside MSF and beyond? What worked and what didn't?

“Including external actors and experts to challenge established ways of working was critical to the project success. 

By involving these outsiders we discovered, for instance, that we were not sterilizing hollow instruments correctly, which is obviously a huge problem. Furthermore, these external actors also helped us solve this problem and design a better solution, so that kind of partnership worked out very well in the end. 

Something that I wish we would have done differently is the planning, communication and expectation management related to the field-testing phase. We simply lacked a systematic contingency plan and we hadn’t really discussed, in detail, the financial commitments and other responsibilities related to potential breakdowns and repairs during the field test. “

 Including external actors and experts to challenge established ways of working was critical to the project success. 

What is next for this case? 

“We are currently in a bit of a holding pattern, but the revised version of the autoclave should preferably be retested in another field context, as the water savings and relative simplicity of the equipment would most likely be a great advantage in other humanitarian settings where there is a need to sterilize complex surgical instruments.

The results so far from the Autoclave case are very promising, however there will never be one size fits all. The SIU will co tinue to work with collaborators, both within and outside of the movement, in order to appropriately iterate the system to generate the maximum possible benefit in assuring the highest quality infection prevention and control in field efforts.”

Read more about the autoclave case in the PROJECT FACT SHEET >>