Infection control first
Trouble-Shooting Instrument Sterilization
By Nancy Andrews, RDH, BS
Instrument sterilization represents the highest level of infection control. Success requires that a sequence of steps be done correctly and in the right order, and equipment must operate correctly. This process is so important that laws require proof of sterilizer cycle validation. While redundancies and overlaps are built in to create a margin of safety, mistakes are possible in the process. The weakest link can allow pathogens to survive and infect. Many mistakes are observable, others are hidden. Sometimes customers are unaware of the issues, but more often, they view them as unsolvable problems. Sales reps can provide leadership and suggestions that will protect patients while making customers’ lives easier.
The process
Instruments must move in a clear path, with space dedicated to workstations:
- contaminated incoming trays/cassettes
- cleaning
- packaging
- sterilization
- aseptic storage.
Limited or poorly organized space may allow breaches in the separation between contaminated and "clean" areas. Cross-contamination must be prevented by separating activities physically, or by cleaning and disinfecting between procedures. Short of remodeling, you may want to suggest reorganizing the space, visible barriers or clear space between work-stations, and perhaps some new equipment.
Map out the flow pattern of instruments. Separate contaminated from sterile areas. Notice other (non-sterilization) activities that can result in cross-contamination being done in the same space: mounting X-rays, writing on charts, lab procedures, or even eating lunch, drinking coffee, or personal hygiene. Dedicate this space to instrument processing!
Converting to cassettes instead of handling individual instruments keeps set-ups together. This simplification reduces time spent handling and re-sorting, and adds safety. Larger equipment may be needed to handle the cassettes, but improved instrument through-put, reduced bottle-necks and improved safety and efficiency will justify the cost. Small-sized cassettes are also an option to ease the transition until a large ultrasonic cleaner, washer/ thermal disinfector and/or sterilizer can be purchased.
Inadequate instrument cleaning before sterilization may be an under-appreciated problem. Cleaning is the necessary first step in sterilization; sterilizers cannot reliably overcome this error. Instruments can only be reliably sterilized if surfaces are clean and if the sterilant (such as steam) reaches all surfaces for the required time.
Thorough processing in an ultrasonic cleaner or washer/disinfector is vital. Pre-cleaning with an enzyme-containing surfactant before these processes can prevent drying of bioburden and remove gross debris, increasing effectiveness of the automated cleaners and reducing contamination of ultrasonic solutions. Spray foam pre-cleaners can "jump-start" the sterilization process, especially if used when instruments must wait to be cleaned, and may be applied after patients are dismissed. Thermal disinfectors save time by automating the cleaning, rinsing and drying of instruments, and also make instruments "safe to handle" for packaging.
Current models of table-top sterilizers have many indicators and records of cycle operation, and most importantly, have automated cycles that reduce potential for human error. Many will not allow alteration of the cycle parameters that might cause failure (such as shortening the cycle). However, even with all the built-in safeguards, workers can; overload chambers, fail to prepare instruments correctly, compromise packaging, fail to wrap instruments, or (especially with older equipment) shorten the cycle. How do workers know if their techniques are compromising sterilization?
Instrument packaging creates an internal environment into which sterilants must penetrate during the sterilization cycle, and then seal to hold sterility until instruments are used. Weekly spore testing (inside and outside packages) is the most reliable confirmation of sterilization, but between tests, each cycle should be monitored by using multi-parameter indicators. These indicate with simple ink color changes, that time, temperature and pressure (presence of steam) have all met minimum thresholds for sterilization. Both single and multi-parameter indicators are now available pre-printed on pouches so that extra strips are not needed. This is much better than "process indicators" that only indicate temperature change, and shows conditions that indicate cycle failure immediately.
Any breach in the wrap is an event that compromises the sterility, requiring re-packaging and processing. Many dental workers are not aware that wet packages may compromise the sterility of instruments, even immediately after sterilization. Contaminants from spray, aerosols, surface debris, or hand contact may "wick" through wet material, and wet packs may be fragile and more likely to tear or puncture. If packs come out of sterilizers wet, and the full cycle, including drying cycle is being run, the equipment service rep should be contacted. New sterilizers, especially those with vacuum technology, have improved drying cycles.
Since "time is money", even single practices are now investing in upgraded instrument sterilization areas with more efficient sterilization equipment such as thermal disinfectors, cassettes and vacuum sterilizers. More immediate, less costly suggestions such as spray enzyme pre-cleaners and pouches with built-in integrators will help increase sterilization success and make life easier for most accounts. [FI]
Nancy Andrews is a nationally recognized speaker, educational consultant, and author; focusing on disease risks, infection prevention, and ergonomics. She is on the California Dental Association, American Dental Association and Organization of Safety and Asepsis Procedures (OSAP) speakers’ bureaus. Contact her at http://nancyandrewsrdh.net
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