Dirty Little Secrets
It’s not easy being green
By Nancy Andrews, RDH, BS
Editor’s Note: Are your customers asking tough hygiene questions? Here is your chance to ask someone "In the Know." Nancy Andrews, RDH, BS, will take your questions and tell your tales. Pulling from centuries of experience, endless education, lots of research, and occasional consultation with other experts, Nancy invites your e-mails at Infectioncontrol@mdsi.org. The best question or tale at the end of the year gets $100.
Q: I noticed that an office was no longer ordering sterilization pouches, so I looked in the sterilization area to see what they were using. I saw that they were using white cloth squares, like table napkins to wrap their instruments in. After digesting this (like a bad hamburger) for a minute, I asked the lead assistant why they had decided to go the route of dinner napkins rather than sterilization pouches. The answer was interesting, and I hope you can tell me how to deal with it. She said "We’re trying to be ‘green,’ and our hygienist remembered that they rolled their instruments in cloth for sterilization when she was in school, so she was sure it was OK. We went to a restaurant supply store and got 100 cloth napkins and just used the lined tape to show it has been processed."
I said I thought it was a great idea to be green, but that their instruments might not stay sterile if they were in cotton wraps. Am I right? I get the feeling they really don’t care if the instruments stay sterile, as long as they have been sterilized since the last patient. In fact, I now see that they lay the unwrapped instruments out on the trays, covered only by the patient bib until they start treatment. If a patient is late or fails, those instruments stay out. What should I say to get them on board with safety regulations?
A: Sterilization of dental instruments is supposed to be the highest form of asepsis in dentistry. Their system has literal holes in it, because the cloth does not seal out contamination. Since cloth is porous, contaminants may enter the pack without being detected. I haven’t heard of wrapping instruments in porous cloth for a while, but it was a common protocol in the 1970s, and maybe in the 1980s. You are right about the important issue of instruments staying sterile until they are used. Today’s pouches and wraps are made of materials that allow the sterilant (steam) to penetrate during sterilization, and prevent contamination after the cycle. This feature of packaging can simply be described as follows: the pores in the packaging material are open and allow the steam or saturated chemical vapor to enter the package and reach instrument surfaces during sterilization cycles. When the materials cool and dry, the pores close, sealing the instruments in a controlled, sterile environment until the package is opened, damaged or compromised. (This is called "event-related" instrument storage protocol.) For example, if water drips on sterile packs, or instruments puncture the wrap, the instruments are no longer considered sterile. Sterilization packages are class II medical devices, require a 510K and they should be free of toxic materials and dyes (not the definition of dinner napkins). Here is the wording from the CDC Guidelines for Infection Control in Dental Healthcare Settings – 2003:
"Packaging materials (e.g., wraps or container systems) allow penetration of the sterilization agent and maintain sterility of the processed item after sterilization. Materials for maintaining sterility of instruments during transport and storage include wrapped perforated instrument cassettes, peel pouches of plastic or paper, and sterilization wraps (i.e., woven and nonwoven). Packaging materials should be designed for the type of sterilization process being used. (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm)
As far as opening packages ahead of patient treatment, there are two important issues: first, the instrument sterility is breached, and contamination is possible. Such lack of control over instruments can lead to contamination and a real exposure, or at least suspicion of possible exposure. That leads to the second issue: patient perception. If patients see instruments sitting out when they enter the operatory they may not trust the asepsis control of the office. That is horrible marketing, and could actually open the door to a lawsuit. If patients contract an infection later, and think the source could have been their dental instruments, there will be trouble for the office (even if nothing can be proven).
Bottom line: Point out the features of acceptable instrument processing packaging, offer product options appropriate for their sterilization technology, and back yourself up with CDC Guidelines. Remember, you will find regulatory references to instrument management mostly in CDC and State Board documents rather than OSHA, since OSHA protects workers rather than patients and does not address instrument packaging specifically.
A question in the spirit of the 70s
Q: I visit an account where two of the dentists have full beards. They wear masks, but the beards stick out all around the masks. One of the dentists has long hair, and usually has it in a ponytail. However, last week, I called on them when his hair was down and it was actually falling on the patient while he worked. Is this legal?
A: The intent of infection control regulatory and professional standards is to prevent infection. If a worker’s personal hygiene or features such as hair create an infection control breach that is impossible to control, standards cannot be met. Your customer’s beard defies mask coverage, so it is likely to become contaminated due to spray and spatter during patient treatment. His long hair can also physically transmit contaminants between the doctor and his patients, and from one patient to the next. Since the wild hair most obviously puts the patients at risk, the State Dental Board is the regulatory body that should have enforceable standards regarding personal hygiene and asepsis standards. Your State Dental Association should have recommendations and be able to direct you to local Public Health Department laws that apply. The Health Department has minimum standards, such as the rules for food services. In short, his hair should be shorter, but if you mention it, your conversation would probably be very short – unless you think he is receptive to your "suggestions."
I’d suggest looking for a larger mask or face shield, and perhaps you might suggest that his hair would be better protected in a hat! Surgical head coverings come in various styles and could remove the cross-contamination risk (or perception of the risk). Good luck with that, since I’d guess his style is more "free."
Bottom line: If a dental worker is cross-contaminating between patients, he or she is not meeting minimum infection control standards. An anonymous complaint can be lodged to the State Board or Dental Association for investigation into patient safety. You just might be able to suggest changes before such a complaint is made.
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