Initial experience with duodenoscopes with single-use end caps in pediatric ERCP: infection prevention comes at a cost.

BACKGROUND AND AIMS: Duodenoscopes with single-use end caps were introduced to minimize infection risk, but they are unstudied in pediatrics. METHODS: We collected clinical data and endoscopists' evaluations of duodenoscopes with single-use end caps versus reusable duodenoscopes over 18 months. RESULTS: A total of 106 ERCPs were performed for patients aged 1 to 18 (mean, 14.2) years. Forty-six involved single-use end caps, with 9 requiring crossover to reusable duodenoscopes. ERCPs involving single-use end caps resulted in more instances of mucosal trauma (10 vs 0; P < .05) and post-ERCP pancreatitis (4 vs 1; P < .05) and accounted for 8 of 9 ERCPs requiring advanced cannulation techniques. No post-ERCP infections occurred. Reported challenges included single-use end cap stiffness and difficulty with their alignment for cannulation. CONCLUSIONS: We report difficulty with advancement, greater reliance on advanced cannulation techniques, and higher rates of post-ERCP pancreatitis when using duodenoscopes with single-use end caps in pediatric ERCP. This area warrants further study.

Excess use of surgical supplies in minimally invasive benign gynecology surgery: an observational study.

BACKGROUND: Single-use materials and equipment are regularly opened by the surgical team during procedures but left unused, potentially resulting in superfluous costs and excess environmental waste. OBJECTIVE: This study aimed to estimate the excess use of surgical supplies in minimally invasive benign gynecologic surgeries. STUDY DESIGN: This is a prospective observational study conducted at a university-affiliated single tertiary medical center. Designated study personnel were assigned to observe surgical procedures performed during July to September 2022. Surgical teams were observed while performing surgeries for benign indications. The teams were not informed of the purpose of the observation to avoid potential bias. Disposable materials and equipment opened during the procedure were documented. Excess supplies were defined as those opened but left unused before being discarded. Costs per item of the excess supplies were estimated on the basis of material and equipment costs provided by the hospital. RESULTS: A total of 99 surgeries were observed, including laparoscopic (32%), robotic (39%), hysteroscopic (14%), vaginal (11%), and laparotomy procedures (3%). Excess use of surgical supplies was documented in all but one procedure. The total cost across all surgeries reached $6357. The contained tissue extraction bag was the most expensive item not used (Applied Medical, Rancho Santa Margarita, CA; $390 per unit) in 4 procedures, contributing 25.54% to the total cost. Raytec was the most common surgical waste, with a total of n=583 opened but unused (average n=5.95 per surgery). A significant difference was found in the rate of excess supplies across the surgical approaches, with robotic surgery contributing 52.19% of the total cost (P=.01). CONCLUSION: Excess use of disposable materials and equipment is common in minimally invasive benign gynecologic surgeries and contributes to superfluous costs and excess environmental waste. It is predominantly attributed to the opening of inexpensive materials that are left unused during the procedure. Increased awareness of costs and generated waste may reduce excess use of surgical supplies and should be further explored in future research.

Perspectives on technology: Single-use catheters - evidence and environmental impact.

OBJECTIVE: To explore the data comparing single- vs multi-use catheters for clean intermittent catheterisation (CIC), consider if the widespread use of single-use catheters is warranted given the cost and environmental impact, and put forth ideas for future consideration. METHODS: A primary literature review was performed in PubMed over the past 50 years. Studies that performed comparative analysis of single- and multi-use catheters were included in our review. All studies that reported on primary data were narratively summarised. RESULTS: A total of 11 studies were identified that reported on primary data comparing single- and multi-use catheters. There was no appreciable evidence suggesting reusable multi-use catheters were inferior to single-use catheters from an infection or usability standpoint. In addition, the environmental and monetary burden of single-use catheters is significant. CONCLUSIONS: The intermittent catheter landscape in the USA has a complex past: defined by policy, shaped by industry, yet characterised by a paucity of data demonstrating superiority of single-use over multi-use catheters. We believe that the aversion to reusable catheters by many patients and healthcare professionals is unwarranted, especially given the cost and environmental impact. Moving forward, better comparative data and more sustainable practices are needed.

Disposable grasper-integrated flexible cystoscope for ureteral stent removal in transplanted patients; focus on feasibility, safety, and patient experience. Results and micro-cost analysis from a tertiary referral center.

INTRODUCTION & OBJECTIVES: To evaluate ureteral stent removal (SR) using a grasper-integrated disposable flexible cystoscope (giFC-Isiris ®, Coloplast ®) after kidney transplantation (KT), with a focus on feasibility, safety, patient experience, and costs. MATERIAL AND METHODS: All consecutive KT undergoing SR through giFC were prospectively enrolled from January 2020 to June 2023. Patient characteristics, KT and SR details, urine culture results, antimicrobial prescriptions, and the incidence of urinary tract infections (UTI) within 1 month were recorded. A micro-cost analysis was conducted, making a comparison with the costs of SR with a reusable FC and grasper. RESULTS: A total of 136 KT patients were enrolled, including both single and double KT, with 148 stents removed in total. The median indwelling time was 34 days [26, 47]. SR was successfully performed in all cases. The median preparation and procedure times were 4 min [3,5]. and 45 s[30, 60], respectively. The median Visual Analog Scale (VAS) score was 3 [1, 5], and 98.2% of patients expressed willingness to undergo the procedure again. Only one episode of UTI involving the graft (0.7%) was recorded. Overall, the estimated cost per SR procedure with Isiris ® and the reusable FC was 289.2€ and 151,4€, respectively. CONCLUSIONS: This prospective series evaluated the use of Isiris ® for SR in a cohort of KT patients, demonstrating feasibility and high tolerance. The UTI incidence was 0.7% within 1 month. Based on the micro-cost analysis, estimated cost per procedure favored the reusable FC.

Advanced trainee perceptions of disposable duodenoscopes and disposable endcaps: results of a nationwide survey.

INTRODUCTION: Disposable duodenoscopes and duodenoscopes with disposable endcaps are being used in clinical practice to reduce or eliminate the risk of transmitting infections. The study aim was to assess perceptions and experiences regarding the use of these duodenoscopes among advanced endoscopy fellows in a nationally representative sample. METHODS: A 17-item electronic survey was sent to 74 advanced endoscopy training programs. The survey was completed by 50 participants and their responses were included for analysis. RESULTS: Most participants were from academic training programs (82.7%) and identified as being in their 7th year of post graduate training (92%; PGY-7). Participants performed an average of 414 ERCPs. 29% reported difficulty with cannulation using disposable duodenoscopes versus 15.7% with duodenoscopes with disposable endcaps (vs. standard duodenoscope). 96% of trainees perceived disposable duodenoscopes as not cost effective and 92% stated they would not use this device during independent practice. 100% of trainees stated that they would use duodenoscopes with disposable endcaps during independent practice. For their most challenging cases, 90% of trainees preferred using standard reprocessable duodenoscopes while no trainee indicated they would prefer using a disposable duodenoscope in this scenario. 82% of participants stated that disposable duodenoscopes and disposable endcaps should be used exclusively or preferentially for high-risk patients citing cost, functionality, and concerns regarding environmental impact. DISCUSSION: Advanced endoscopy fellows perceive disposable duodenoscopes as impacting technical maneuverability. Concerns about functionality, cost effectiveness and environmental impact are barriers to adoption.

A Cost and Waste-Savings Comparison Between Single-Use and Reusable Pulse Oximetry Sensors Across US Operating Rooms.

BACKGROUND: Operating room (OR) expenditures and waste generation are a priority, with several professional societies recommending the use of reprocessed or reusable equipment where feasible. The aim of this analysis was to compare single-use pulse oximetry sensor stickers ("single-use stickers") versus reusable pulse oximetry sensor clips ("reusable clips") in terms of annual cost savings and waste generation across all ORs nationally. METHODS: This study did not involve patient data or research on human subjects. As such, it did not meet the requirements for institutional review board approval. An economic model was used to compare the relative costs and waste generation from using single-use stickers versus reusable clips. This model took into account: (1) the relative prices of single-use stickers and reusable clips, (2) the number of surgeries and ORs nationwide, (3) the workload burden of cleaning the reusable clips, and (4) the costs of capital for single-use stickers and reusable clips. In addition, we also estimated differences in waste production based on the raw weight plus unit packaging of single-use stickers and reusable clips that would be disposed of over the course of the year, without any recycling interventions. Estimated savings were rounded to the nearest $0.1 million. RESULTS: The national net annual savings of transitioning from single-use stickers to reusable clips in all ORs ranged from $510.5 million (conservative state) to $519.3 million (favorable state). Variability in savings estimates is driven by scenario planning for replacement rate of reusable clips, workload burden of cleaning (ranging from an additional expense of $618k versus a cost savings of $309k), and cost of capital-interest gained on investment of capital that is freed up by the monetary savings of a transition to reusable clips contributes between $541k (low-interest rates of 2.85%) and $1.3 million (high-interest rates of 7.08%). The annual waste that could be diverted from landfill by transitioning to reusable clips was found to be between 587 tons (conservative state) up to 589 tons (favorable state). If institutions need to purchase new vendor monitors or cables to make the transition, that may increase the 1-time capital disbursement. CONCLUSIONS: Using reusable clips versus single-use stickers across all ORs nationally would result in appreciable annual cost savings and waste generation reduction impact. As both single-use stickers and reusable clips are equally accurate and reliable, this cost and waste savings could be instituted without a compromise in clinical care.

Institutional Micro-Cost Comparative Analysis of Reusable vs Single-use Cystoscopes With Assessment of Environmental Footprint.

OBJECTIVE: To conduct a comparative cost analysis between single-use and reusable cystoscopes from a national healthcare system perspective and assess the environmental footprint. METHODS: Single-center micro-cost analysis of reusable vs single-use cystoscopes used institutional data. The cost breakdown included capital, reprocessing, repair, procedure, and environmental impact expenses. Data collection occurred in 2022, utilizing registered data, observations, and expert opinions. Depreciation was applied over 5 years for reusable cystoscopes and 8 years for the automated endoscope reprocessor. Deterministic sensitivity analyses gauged result robustness to input variations. Lastly, an assessment of the environmental footprint, focusing on water consumption and waste generation, was conducted. RESULTS: Per-procedure cost associated with reusable cystoscopes was €332.46 vs €220.19 associated with single-use, resulting in savings of €112.27. When projecting these costs per procedure with the number of procedures performed in 2022 (1186), comparing the costs of procedures performed in 1 year with reusable endoscopes (€394,295.86) to the costs of the exact number of procedures performed with disposable endoscopes (€261,149.37), a saving of €133,146.49 could be achieved. Additionally, after continuous use of single-use endoscopes, procedures were scheduled every 20 minutes instead of every 30 minutes. This adjustment allowed for 15 daily procedures instead of 10 while maintaining the same shift. This suggests potential advantages in terms of improved organizational impact and reduced waiting lists. Ultimately, the decreased environmental impact favored the adoption of single-use cystoscopes. CONCLUSION: Our study presents an opportunity for organizational development in response to the evolving external environment, considering user needs, market dynamics, and competition with other facilities.

A systematic review comparing the safety, cost and carbon footprint of disposable and reusable laparoscopic devices.

INTRODUCTION: The objective of this systematic review of the literature is to compare a selection of currently utilized disposable and reusable laparoscopic medical devices in terms of safety (1st criteria), cost and carbon footprint. MATERIAL AND METHODS: A search was carried out on electronic databases for articles published up until 6 May 2022. The eligible works were prospective (randomized or not) or retrospective clinical or medical-economic comparative studies having compared disposable scissors, trocars, and mechanical endoscopic staplers to the same instruments in reusable. Two different independent examiners extracted the relevant data. RESULTS: Among the 2882 articles found, 156 abstracts were retained for examination. After comprehensive analysis concerning the safety and effectiveness of the instruments, we included four articles. A study on trocars highlighted increased vascular complications with disposable instruments, and another study found more perioperative incidents with a hybrid stapler as opposed to a disposable stapler. As regards cost analysis, we included 11 studies, all of which showed significantly higher costs with disposable instruments. The results of the one study on carbon footprints showed that hybrid instruments leave four times less of a carbon footprint than disposable instruments. CONCLUSION: The literature on the theme remains extremely limited. Our review demonstrated that from a medical and economic standpoint, reusable medical instruments, particularly trocars, presented appreciable advantages. While there exist few data on the ecological impact, those that do exist are unmistakably favorable to reusable instruments.

Value for money of reusable versus disposable ophthalmic instruments for intravitreal injections.

AIM: The aim of this study was to follow the instruments' pathways and cost each segment to calculate whether reusable or disposable ophthalmic instruments offer better value for money for intravitreal injections. METHODS: The cycles and costs of reusable and single-use disposable instruments used for intravitreal injections were mapped out, including purchase costs, transport to and from the place of use, opening and disposal, sterilisation, replacement, salary costs of staff involved, etc. results: The cost of using reusable instruments for intravitreal injections (NZ$29.00) was lower than the cost of using disposable instruments ($30.51) by $1.51 per patient. CONCLUSIONS: Intravitreal injections performed with reusable instruments offer better value for money than when performed with disposable instruments. This equates to a beneficial financial saving just for this one low-complexity case. Such savings can multiply significantly when considering the instruments used in a wider variety of ophthalmic procedures. There are of course trade-offs between safety, quality, cost and sustainability.

Disposable Gastrointestinal Scopes: A Systematic Review.

OBJECTIVE: Endoscopes are an essential tool in the diagnosis, screening, and treatment of gastrointestinal diseases. In 2019, the Food and Drug Administration issued a news release, recommending that duodenoscope manufacturers and health care facilities phase out fully reusable duodenoscopes with fixed endcaps in lieu of duodenoscopes that are either fully disposable or those that contain disposable endcaps. With this study, we systematically reviewed the published literature on single-use disposable gastrointestinal scopes to describe the current state of the literature and provide summary recommendations on the role of disposable gastrointestinal endoscopes. MATERIALS AND METHODS: For our inclusion criteria, we searched for studies that were published in the year 2015 and afterward. We performed a literature search in PubMed using the keywords, "disposable," "reusable," "choledochoscope," "colonoscope," "duodenoscope," "esophagoscope," "gastroscope," and "sigmoidoscope." After our review, we identified our final article set, including 13 articles relating to disposable scopes, published from 2015 to 2023. RESULTS: In this review, we show 13 articles discussing the infection rate, functionality, safety, and affordability of disposable gastrointestinal scopes in comparison to reusable gastrointestinal scopes. Of the 3 articles that discussed infection rates (by Forbes and colleagues, Ridtitid and colleagues, and Ofosu and colleagues), each demonstrated a decreased risk of infection in disposable gastrointestinal scopes. Functionality was another common theme among these articles. Six articles (by Muthusamy and colleagues, Bang and colleagues, Lisotti and colleagues, Ross and colleagues, Kang and colleagues, and Forbes and colleagues) demonstrated comparable functionality of disposable scopes to reusable scopes. The most reported functionality issue in disposable scopes was decreased camera resolution. Disposable scopes also showed comparable safety profiles compared with reusable scopes. Six articles (by Kalipershad and colleagues, Muthusamy and colleagues, Bang and colleagues, Lisotti and colleagues, Luo and colleagues, and Huynh and colleagues) showed comparable rates of AEs, whereas 1 article (by Ofosu and colleagues) demonstrated increased rates of AEs with disposable scopes. Lastly, a cost analysis was looked at in 3 of the articles. Two articles (by Larsen et al and Ross and colleagues) remarked that further research is needed to understand the cost of disposable scopes, whereas 1 article (by Kang and colleagues) showed a favorable cost analysis. CONCLUSIONS: After a review of the literature published since the 2015 Food and Drug Administration safety communication, disposable scopes have been shown to be effective in decreasing infection risks while maintaining similar safety profiles to conventional reusable scopes. However, more research is required to compare disposable and reusable scopes in terms of functionality and cost-effectiveness.

The Financial Implications of a Single-Use Device Reprocessing Program at a Tertiary Referral Center Surgical Department.

The operating room has been identified as one of the primary contributors to waste and energy expenditure in the health care system. The primary objective of our study was to evaluate the efficacy of single-use device reprocessing and report the cost savings, waste diversion, and reduction in carbon emissions. Data was collected from January 2021 to April 2023. Medline collected the data for analysis and converted it from an Excel file format to SPSS (Version 27) for analysis. Descriptive frequencies were used for data analysis. We found a mean monthly cost savings of $16,051.68 and a mean 700.68 pounds of waste a month diverted, resulting in an estimated yearly saving of $2354.29 in disposal costs and a reduction of 1112.65 CO2e emissions per month. This program has made significant contributions to cost savings and environmental efforts.

Does Reusable Instrumentation for Four-Anchor Rotator Cuff Repair Offer Decreased Waste Disposal Costs and Lower Waste-Related Carbon Emissions?

INTRODUCTION: Orthopaedic surgery is culpable, in part, for the excessive carbon emissions in health care partly due to the utilization of disposable instrumentation in most procedures, such as rotator cuff repair (RCR). To address growing concerns about hospital waste, some have considered replacing disposable instrumentation with reusable instrumentation. The purpose of this study was to estimate the cost and carbon footprint of waste disposal of RCR kits that use disposable instrumentation compared with reusable instrumentation. METHODS: The mass of the necessary materials and their packaging to complete a four-anchor RCR from four medical device companies that use disposable instrumentation and one that uses reusable instrumentation were recorded. Using the cost of medical waste disposal at our institution ($0.14 per kilogram) and reported values from the literature for carbon emissions produced from the low-temperature incineration of noninfectious waste (249 kgCO 2 e/t) and infectious waste (569 kgCO 2 e/t), we estimated the waste management cost and carbon footprint of waste disposal produced per RCR kit. RESULTS: The disposable systems of four commercial medical device companies had 783%, 570%, 1,051%, and 478%, respectively, greater mass and waste costs when compared with the reusable system. The cost of waste disposal for the reusable instrumentation system costs on average $0.14 less than the disposable instrumentation systems. The estimated contribution to the overall carbon footprint produced from the disposal of a RCR kit that uses reusable instrumentation was on average 0.37 kg CO2e less than the disposable instrumentation systems. CONCLUSION: According to our analysis, reusable instrumentation in four-anchor RCR leads to decreased waste and waste disposal costs and lower carbon emissions from waste disposal. Additional research should be done to assess the net benefit reusable systems may have on hospitals and the effect this may have on a long-term decrease in carbon footprint. LEVEL OF EVIDENCE: Level II.

Lack of Association of Pediatric Surgical Patient Outcomes With Increased Disposable Operating Room Supply Costs.

INTRODUCTION: There is wide variation in the cost of disposable operating room supplies between surgeons performing the same operation at the same institution. The general relationship between variation in disposable supply cost and patient outcomes is unknown. We aimed to evaluate the relationship between disposable supply cost and patient outcomes for sixteen common operations. METHODS: Cost data were reviewed for the most common procedures performed by five surgical divisions at a single children's hospital over a six-month period in 2021. For procedure, the median disposable OR costs were calculated. Each operation performed was categorized as low cost (below the group median) or high cost (above the group median. We compared the rates of adverse events (clinic visit within 5 days, 30-day emergency department visit, unplanned reoperation, unplanned readmission, anesthesia complications, prolonged hospital length of stay, need for blood product transfusion, or death) between procedures with low and high disposable supply costs. RESULTS: 1139 operations performed by 48 unique surgeons from five specialties were included; 596 (52%) were low-cost and 543 (48%) high-cost. The low and high-cost groups did not differ regarding most demographic characteristics. Overall, 21.9% of children suffered any adverse outcome; this rate did not differ between the low and high-cost groups when evaluated individually or in aggregate (20.5% vs 23.6%, p = 0.23). CONCLUSION: Our data demonstrate that across a wide range of pediatric surgical procedures, the cost of disposable operating room supplies was not associated with the risk of adverse outcomes. LEVEL OF EVIDENCE: Level 3.

Costs of reusable and disposable aprons in a public teaching hospital / Costos de delantales de tejido reutilizables y de desechables en hospital universitario público / Custos de aventais de tecido reutilizáveis e de descartáveis em hospital universitário público

Objective To analyze the direct cost of reusable and disposable aprons in a public teaching hospital. Method Cross-sectional study of quantitative approach, focusing on the direct cost of reusable and disposable aprons at a teaching hospital in northern Paraná. The study population consisted of secondary data collected in reports of the cost of services, laundry, materials and supplies division of the institution for the year 2012 Results We identified a lower average cost of using disposable apron when compared to the reusable apron. The direct cost of reusable apron was R$ 3.06, and the steps of preparation and washing were mainly responsible for the high cost, and disposable apron cost was R$ 0.94. Conclusion The results presented are important for hospital managers properly allocate resources and manage costs in hospitals
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Objetivo Analizar el costo directo de delantales de tejido reutilizables y de desechables en hospital universitario público. Método Estudio transversal de abordaje cuantitativo, con énfasis en el costo directo de los delantales de tejido reutilizables y desechables, realizado en hospital universitario del norte de Paraná. La población de estudio estuvo compuesta de datos secundarios recogidos en informes de los servicios de costo, lavandería, división de material y provisiones de la institución, referentes al año de 2012. Resultados Se identificó un menor costo medio de utilización del delantal desechable cuando comparado con el costo del delantal de tejido reutilizable. El costo directo de utilización del delantal de tejido fue de R$3,06, siendo las etapas de confección y lavado las principales responsables de la elevación del costo, y el delantal desechable costó R$0,94. Conclusión Los resultados presentados constituyen herramientas para que los gestores hospitalarios puedan destinar adecuadamente los recursos y gestionar los costos en instituciones hospitalarias. .

Objetivo Analisar o custo direto de aventais de tecido reutilizáveis e de descartáveis em hospital universitário público. Método Estudo transversal de abordagem quantitativa, com enfoque no custo direto de aventais de tecido reutilizáveis e de descartáveis, realizado em hospital universitário do norte do Paraná. A população de estudo foi composta por dados secundários coletados em relatórios dos serviços de custo, lavanderia, divisão de material e suprimentos da instituição, referentes ao ano de 2012. Resultados Identificou-se um menor custo médio de utilização do avental descartável quando comparado ao do avental de tecido reutilizável. O custo direto de utilização do avental de tecido foi de R$ 3,06, sendo as etapas de confecção e lavagem as principais responsáveis pela elevação do custo, e o avental descartável custou R$ 0,94. Conclusão Os resultados apresentados constituem ferramentas para que os gestores hospitalares possam alocar adequadamente os recursos e gerenciar custos em instituições hospitalares.


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Cálculo dos custos do reprocessamento de pinças de uso único utilizadas em cirurgia video-assistida / Calculation of the reprocessing costs of single-use tongs used in video-assisted surgeries

O trabalho objetivou desenvolver proposta metodológica para cálculo dos custos do reprocessamento de pinças de cirurgia vídeoassistida de uso único. O reuso freqüente desses artigos ocorre pelo alto custo, entretanto, poucos estudos foram desenvolvidos a respeito desse enfoque. Elaborou- se um fluxograma com cada fase de reprocessamento, permitindo identificação dos componentes dos custos quanto à mão- de- obra, materiais e gastos indiretos. Pautado nesses dados, pôde-se construir a proposta metodológica para o cálculo de custos, baseada no método de custeio por absorção, incluindo a planilha para coleta de dados.

The frequent reuse of disposable forceps instruments is justified by their high cost. However, few studies have been carried out on this topic. The objective ofthis study was to develop a methodological proposal for calculatingthe reprocessing costs for these instruments used in videoassistedsurgery. A flowchart was developed for each phase of the reprocessing. This allowed subsequent identification of the cost components in terms of labor, materials and indirect expenses. From these data, a methodological proposal for cost calculation could be created, based on the Full Absorption Costing Method, including the spreadsheet for data collection.

El trabajo tuvo como objetivo desarrollar propuesta metodológicapara el cálculo de los costos del reprocesamiento de pinzas de cirugía video-asistida de uso único. El uso frecuente de esos artículos ocurre por el alto costo, no obstante, pocos estudiosfueron desarrollados respecto a ese enfoque. Se elaboró un fluxogramacon cada fase del reprocesamiento,permitiendo la identificación de los componentes de los costos en cuanto a la mano de obra, materiales y gastosindirectos. Teniendo como pauta esos datos, se puede construir la propuesta metodológica para el cálculo de costos, con base en el método de costeo por absorción, incluyendo la planilla pararecolección de datos.

Cobertura quirúrgica ¿Textil o desechable? / Surgical coverings: textile or disposable?

Dados los cambios acaecidos en los materiales utilizados en los ámbitos quirúrgicos, así como el desarrollo de nuevos productos que proporcionan mayor seguridad y las nuevas directivas de calidad, conviene realizar una revisión de los sistemas de trabajo en estas salas tan sumidas en riesgo de infección, la evolución de los tejidos y la normativa legal al uso (AU)

Given the changes occurring in materials used in surgical environments, as well as the development of new products which provide greater safety and the new quality guidelines, it is important to revise the Word systems in these units with a high risk on infection, the development of textiles and the legal regulations of use (AU)