Being mindful of what you should – and shouldn’t – do is important to ensure a safe environment.
There’s a lot that goes into the dental practice’s infection prevention efforts. There are, of course, processes and procedures that should seem fairly straightforward, like practicing good hand hygiene and using personal protective equipment. However, other things require a bit more knowledge and initiative on the practice’s part. That is especially true when it comes to instrument processing.
The following are three important do’s and don’ts of effective instrument processing.
DO: Provide training
It all starts by ensuring that staff know how to properly process instruments.
“For personnel who are actually doing the processing, they must have appropriate and adequate training,” says Kathy Eklund, RDH MHP, director of occupational health and safety at The Forsyth Institute. “Education and training is a key element of a sterility assurance program.”
“That’s so important because, otherwise, they will do things they’ve done for a long time and there can be errors,” adds Jackie Dorst, RDH, BS, an infection prevention consultant and speaker. “It’s not always a matter of just doing what you’ve always been doing. The practice should have a point person who is responsible to make sure everyone knows what they’re doing.”
Spearheading those education efforts should be a point person responsible for keeping up on education, standards and recommendations.
“It needs to be someone who is constantly updating their own information and is staying current with the state dental board regulations and CDC’s guidelines,” Dorst says. “And often, if it’s someone who hasn’t been through a current training course in the last 20 years, they may be using older information that is no longer accurate. I see that often. There’s a lack of training. Very often, the sterilization tech, as it is referred to, is an entry-level position in the dental office.”
Sterilization isn’t something that should be learned as fast as possible. Rather, it involves plenty of education and know-how.
“Often, they’ll come into the office and they’ll observe for a day, and then they start doing it,” Dorst notes. “And they don’t get thorough training that provides them with knowledge and information to make knowledgeable decisions about each step of the sterilization process. CDC specifically says that sterilization is a complex process requiring specialized equipment, adequate space, qualified healthcare providers – who are provided with ongoing training – and regular monitoring for quality assurance. That’s the cornerstone of instrument sterilization.”
Training isn’t hard to come by, and for those who want more in-depth education, resources are readily available.
“There are a variety of continuing education courses out there, but there are also certification courses as well,” Eklund says. “For instance, most hospitals, large healthcare settings – including many dental schools – employ certified sterile processing technicians for processing medical instruments and devices. And that certification training requires both didactic coursework and a number of hours of hands-on observation and experience. Many dental offices do not have certified sterile processing technicians.”
Dorst says that the optimal educational opportunity is as close as your computer via the Organization for Safety, Asepsis and Prevention (OSAP).
“OSAP provides, as part of their membership, their ‘Infection Control in Practice,’ which is a bi-monthly update on training issues, and it has continuing education associated with it,” Dorst says. “It actually provides a training module that the infection prevention leader, or coordinator, in the office could use in updated training throughout the year with the team.”
Up next: Conducting validation...
DO: Conduct validation
Going through all the steps to ensure instruments are properly processed is, of course, a necessary step. But once those instruments have been processed, how do you know that they’re sterile?
“Have an appropriate sterility assurance program, which involves appropriate monitoring, minimal weekly biological monitoring, or more often,” Eklund says. “In addition to, minimally, weekly biologic monitoring, the CDC recommends that each package of instruments contain an internal chemical indicator. Other examples of monitoring include function tests for the equipment that you’re using in the processing area: sterilizer, instrument washer, ultrasonic unit. The manufacturer of the specific equipment should provide the appropriate function test, and frequency of testing, for their equipment.”
“They must validate each step of the instrument reprocessing, and that means validate cleaning, validate packaging, validate sterilization,” Dorst adds. “The current general recommendation, nationwide, is to do a spore test once a week, and that provides validation that the sterilizer is working.”
Validating cleaning seems harder to track. Just because a machine is making noise doesn’t mean that it’s working.
“There is a gap in knowledge out there about how an ultrasonic cleans instruments – which is by cavitation – and how you test for that is by doing a simple aluminum foil test,” Dorst explains. “They can take a piece of regular weight aluminum foil and they hold it in the ultrasonic for 20 to 30 seconds, depending on the instructions from their equipment manufacturers. And when that aluminum foil is removed from the ultrasonic cleaning solution and visually examined, it should have uniform dimpling, little pits, maybe even holes in there, if the ultrasonic is cavitating, if it is creating the bubbles that implode that pulls the debris off of the instruments. If the aluminum foil comes out shiny, then their ultrasonic is making noise, but it’s not cleaning; it’s just soaking the instruments in a cleaning solution, but it’s not clean.”
A less common, but very effective, way to monitor the sterilization process is through use of a Process Challenge Device (PCD).
A PCD usually consists of a Type 5 chemical integrator indicator in a pre-assembled challenge test pack. The PCD is placed in each sterilization load where the biologic monitor is placed.
“A PCD with a Type 5 Chemical Integrator does not replace weekly biological monitoring,” Eklund says. “The chemical integrator indicator in the PCD should be checked before the actual load of instruments is released for use. The use of a PCD is a value-added quality assurance tool.”
Up next: Keeping good records...
DO: Keep good records
Good recordkeeping can help to ensure all the necessary steps have been taken and, if there is a problem, can help track down affected instruments.
“That means keeping records on the cleaning process, on the sterilization process, and being able to provide those records, should they have an inspection, or a failure, a breach,” Dorst says. “It needs to be at specific information. With the ultrasonic, I would write on there that I filled it each day and then emptied it each day, or more frequently, as needed. And then I would recommend testing with the aluminum foil, and for organization, I recommend testing once a week. I recommend that they have their ultrasonic cleaning equipment tested on the same day that they do their spore test on their sterilizer. That would be their validation day.”
Some equipment automatically maintains records. But in some cases, good old pen and paper might just be the best tools.
“The CDC, with their ‘2016 Summary of Infection Prevention Practices in Dental Settings’ publication, raises the validation standards and said that records should be kept on each sterilization cycle – a record of when the cycle was started, what time the cycle ended, did the cycle complete, and did the indicators on these packages change color? That should be signed off on. They can either keep those on a digital log that’s provided with some of the sterilization equipment. It’s automatically recorded, digitally, onto a USB drive that can be downloaded to the central server, and they could have a sterilization file folder in there. Or it could be a handwritten log that they keep and each person signs off on in the sterilization room. Keeping a handwritten document can be the easiest for them to manage because they don’t always have a computer monitor right there in the sterilization room.”
DON’T: Improperly package instruments
There are specific ways in which instruments should be packaged. Failure to do so invites contamination.
“The breach that I see often is that they’ll fold the top of the pouch over more than they should,” Dorst says. “It must be folded on the perforated line. If they try to make that package smaller, because they’ve got a small instrument it, then that invalidates sterilization because it leaves a gap in the seal. And even with cassettes, the cassettes have to be properly sealed. And they have an internal indicator inside either the pouch or the cassette.”
Most instruments need to be packaged, but only certain types of instruments aren’t.
“Don’t sterilize instruments or handpieces unwrapped or unpackaged,” Eklund says. “Items that are sterilized unpackaged are called immediate use sterilization, and it’s only intended for items that cannot be packaged and must be transported to the treatment field in a sterile manner and used immediately. This is very difficult to accomplish in a dental setting. Most dental instrument and handpiece manufacturer’s instructions/directions for processing include packaging the items for sterilization and storage. Items to be sterilized should be packaged prior to sterilization, and remain in the package, to the point of use. In other words, open the package of instruments in front of the patient.”
Up next: Overloading the sterilizer...
DON’T: Overload the sterilizer
Like an elevator that can only hold 10 people, sterilizers can only hold so much. Overloading the sterilizer can lead to inadequately processed equipment, including improperly dried sterile packages.
“Sterile packages should not be wet upon removal from the sterilizer,” Eklund says. “Sometimes that has to do with inappropriate loading. Your packages, whether they’re wrapped cassettes or plastic/paper pouches, should have space between each package so that there is appropriate circulation of the steam heat that penetrates the packaging material to reach all surfaces of the items to be sterilized. But if you layer packages - actually lay them on top of each other - the packaging material may not dry properly. Consult the manufacturer’s directions for your sterilizer for instructions on proper loading.”
Wet packets damage the integrity of the packaging materials and invite contamination.
“You don’t want to remove wet packaging because the paper that is used to either wrap cassettes or the paper that is used to construct the pouches is a special type of paper that – when it’s exposed to steam – the fibers of the paper expand and allow the steam to penetrate in and touch the instruments,” Dorst says. “At the end of the cycle, when the drying process goes on, those fibers contract and therefore seal out the pores where the microorganisms could enter and re-contaminate instruments. So, it’s important to let the instruments dry inside the sterilizer before removing them, otherwise those pores are still open, the fibers are still separated. When the pouches are wet, they’re very fragile and instruments will poke through them.”
DON’T: Disinfect semi-critical items
Always ensure that items are disinfected according to the manufacturer’s instructions. For instance, chemical disinfectants aren’t a shortcut.
“Don’t use a surface disinfectant on wiping down, maybe, cheek retractors or on other items,” Dorst says. “They think, ‘Oh, well, that doesn’t need to go through sterilization. I’ll just wipe it with a disinfectant.’ Disinfectants are regulated by the Environmental Protection Agency (EPA) as pesticides. So, in essence, they’re wiping down a semi-critical item that’s going to go into the patient’s mouth with a pesticide and leaving potentially residual chemicals in there that could either be toxic to the patient or cause an allergic reaction. I see that so frequently in offices. Those surface disinfectants are only for touch and splash surfaces that are either environmental or non-critical items, meaning those items that do not go with the patient’s mouth.”
Instrument processing involves very exacting details. And being mindful of what you should – and shouldn’t – do is important to ensure a safe environment.
For more information about infection control best practices, visit CDC’s Infection Prevention & Control in Dental Settings website www.cdc.gov/oralhealth/infectioncontrol/index.html.
The CDC also offers a free mobile app for tablets and smart phones called DentalCheck. It provides a helpful checklist that dental professionals can use to ensure that they’re covering all their bases. The app can be found at: www.cdc.gov/oralhealth/infectioncontrol/dentalcheck.html.
Information on the Certified Registered Central Service Technician (CRCST) Certification can be found at the IAHCSMM website: www.iahcsmm.org/certification-menu/crcst-certification.html.