Dirty Little Secrets
Right tools, wrong cleaning strategy
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 call on a group practice that re-modeled their office last year. I helped them with the process, and it was long and involved, but very successful - I thought! They installed a new instrument processing center with a washer-disinfector, and invested in cassettes. Everything is beautiful, with enough space and organization to streamline their sterilization processes. I’ve heard nothing but raves about the improved efficiency, less time spent on instruments, and preservation of instruments.
But, recently, the doctor called to complain that his instruments were stained and corroded. So I asked the obvious questions about cleaning, rinsing and asked if they were putting burs in with their instruments. Then I stopped by and watched what they were doing. I was surprised that the new assistant was bundling her instrument sets in hair-ties and putting the bundles in the washer inside a deep basket (purchased from a restaurant supply store). She then put the instruments in pouches while still wet and autoclaved them. Some still had the bands on! She had quit using the cassettes for cleaning and autoclaving to "save space and get more instruments in the sterilizer." Right before she set up, she put the instruments in an open cassette, then on a tray. The cassettes were not sterile, but were being wiped off with a surface disinfectant between each use. She said they didn’t have enough cassettes anyway, so she just used one half of the cassette to "set out the instruments."
When we all discussed it, the doctor reasoned that instruments are put on non-sterile surfaces or paper covers anyway, so he wanted to let her do what works for her. Does any of this make sense?
A: Great job investigating this. I wonder how many times one non-compliant employee undermines the success of an office. The doctor has invested in state-of-the-art systems and equipment, but a new assistant is not using it correctly.
Let’s start here: Instruments are getting corroded, and not being cleaned. Bundling dirty instruments together with elastic bands eliminates free space around individual instruments that is necessary for effective pre-cleaning (true for both ultrasonic baths and automatic washers). To keep instruments together, the new assistant replaced cassettes with a system that also takes a lot of time, and increases risk of injury while handling instruments. Cassettes contain, organize and protect instruments with the necessary instrument separation to allow cleaning and sterilization. This might work for her, but it’s not the correct way to do it.
Wiping down cassettes rather than sterilizing instruments in them is a bad idea. The cassettes have complex shapes and surfaces that would be difficult to effectively "wipe clean." The likelihood of cross-contamination is huge. Cassettes should be immersed, cleaned, dried and sterilized with the instruments between uses. Paper tray covers (as the doctor correctly identified as "non-sterile") are single-use disposable items and if used correctly, should not cross-contaminate. Using cassettes without sterilizing them as she is doing is not standard practice, and should be considered a breach in infection control standards.
Instruments should be cleaned and rinsed well before autoclaving, unless a conditioner is meant to be left on the instruments during sterilization. This is a basic requirement of sterilizers. Bundling instruments may interfere with rinsing and the detergent residue can discolor and corrode instruments during sterilization. By the way, good call on the burs, or mixing metals in loads - this can cause corrosion.
One must ask why this assistant is defeating the benefits of the office’s systems. Here are some points to discuss with the customer:
- Cassettes save time and money and protect instruments, workers and patients from injury and cross contamination. But they must be used correctly.
- Instruments should be loose enough to allow cleaning, rinsing, drying and sterilizing agents to contact all surfaces.
- Cassettes maintain organization of set-ups throughout re-processing. Instruments should be kept in them. The cassettes should be the module that is processed rather than individual instruments.
- Cassettes come in all sizes - make sure offices have enough cassettes, and the full range of sizes they need so they are not tempted to abandon the system.
- Make sure the washer is working and they are using the right cleaning products with it. A common problem is burs getting stuck in the holes of the water spray openings and blocking water spray. Check that out.
- If sterilizer space is an issue, flat wrap adapts more closely to the cassette contour, whereas pouches extend beyond the cassette. Packaging should not touch a sterilizer’s inside walls. Or, if they’re out of cassettes, maybe the practice has grown and they need a larger (or another) sterilizer.
This story shows how just one "non-believer" can undo progress and threaten everyone’s safety - and also the success of the business. Customers may invent solutions to real or perceived problems. Great job taking the time to deconstruct the problem. By "hanging around" and observing, you found out how to get the account back on track!
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