As there can always be equipment malfunctions, it is important for your practice to be prepared for these instances.
It is never easy when a practice equipment breaks down. That being said, there are some pieces of equipment that are worse to break down than others. One operatories handpiece breaking isn’t likely to cripple the entire practice. However, if something like a sterilizer or an autoclave is out of commission, the whole practice can suffer.
“You’ve got to have a sterilizer,” Jackie Dorst, RDH, BS observes. Dorst is an infection prevention consultant and speaker. “And if that sterilizer breaks down, you can’t reprocess instruments. And if you don’t have a sterile pack of instruments, say for a root canal or for a crown prep, and that’s your next patient, then your only alternative is to cancel that patient and reschedule them.”
“The biggest issue with something like that, of course, is that you’ve got critical equipment,” Douglas Risk, DDS, says. Dr Risk is the Compliance Manager and private practitioner at Tidewater Dental in Southern Maryland, serves on the Executive Board of Directors for OSAP, is a Diplomate of the American Board of General Dentistry, and is a Fellow of the International College of Dentists. “You cannot get sterile with any other piece of equipment. Cold sterilization is not a recommendation for anything in dentistry. High-Level disinfection is not a recommendation for dental instruments, and it’s not for any critical items. So, basically, if your sterilizer goes out and you have no backup, then you can’t reprocess any instruments. You could use what’s already sterile until those items run out, and then you can’t go any further. It’s just like the guy that is on the assembly line. If there’s only one guy that knows how to use a piece of equipment, then that person can never go on vacation, because nobody else can run it and the assembly line will stop. The practice really has to stop practicing dentistry using sterile equipment.”
The practice may not, necessarily, be dead in the water, but it’s not going to be able to operate as it normally would.
“You can do things that don’t require sterilization,” Dr Risk says. “You can use disposable items. A lot of places make impressions with disposable trays, radiographs, or use sensors that have barriers so forth like that. But, you’re done with instruments that need to be sterile.”
An easy solution – albeit costly – is to add redundancy to the practice. That is, have at least 2 sterilizers in the steri-center.
“You don’t have an alternative if the 1 and only sterilizer breaks down,” Dorst says. “And at this time, most dental practices have 2 sterilizers. They may have 1 that is a tabletop sterilizer that has a larger chamber, like a 10-inch, 11-inch chamber, or maybe even larger if they’re a really busy practice. And then they’ll probably have a second sterilizer that is a fast turnaround-type sterilizer, such as a Statim.
“It has a smaller chamber,” she continues. “We’ve used Statim autoclaves to quickly sterilize items that are expensive, and we might not have as large of an inventory, such as handpieces. If that big tabletop sterilizer that practices are using for the bulk of their instruments and for their cassettes should break down, then they could get by using a Statim until that tabletop sterilizer is repaired, although it would really slow them down and compromise them.”
Utilizing a second sterilizer doesn’t mean that the practice has to break the bank. It’s perfectly reasonable to include a second, smaller sterilizer that will help relieve the day-to-day load, as well as step in should an emergency arise.
“There are various types and various sizes of sterilizers,” Dr Risk observes. “There’s, obviously, several different prices from $5,000, for instance, all the way up to $80,000. So, you don’t have to have a backup for an $80,000 sterilizer unless you have a big operation. For instance, we have 10 treatment rooms in our office, and we have 2 sterilizers, 1 that’s a little bit larger, 1 that’s a little bit smaller. And just about everything that we have or use will fit in the smaller ones, just not in the volume, but we could split up the pack and put it in the smaller sterilizer without that much trouble. And we could keep going with the basic types of services that we provide.”
As with anything, the best way to avoid a problem is to keep up on routine maintenance. And, for equipment at the dental practice, that starts with that equipment manufacturer’s instructions for use.
“It’s important for the dental practice to have the manufacturer’s instructions for use for their sterilizer equipment,” Dorst says. “In the dental practice, we are using autoclaves and autoclaves use distilled water to make steam. It’s a complex process of steam sterilizing instruments, and with the water and the heating elements, there’s a potential for damage – over the years – that can happen. The gasket can get hard or deteriorate. If there are leaks around the edge of that gasket, then you can’t achieve the pressure it needs. So, having the manufacturer’s instructions for use informs the team how to do the weekly maintenance, the monthly maintenance, and even the yearly maintenance on it, and that includes checking the gasket for complete seals; wiping down the interior of the chamber, ensuring that there are not any oils or minerals that have built up on the inside.”
Keeping up on recommended maintenance is not only good for the equipment, but ultimately, the practice’s overall performance.
“If the autoclave-type of sterilizer fails, there are other types of sterilization,” Dorst observes. “There are ethylene oxide and other sterilizing agents, but they require a lot more safety precautions, because of the toxicity of the sterilizing agent. So, autoclaves are pretty much the standard in dental. And if the autoclave fails, and it’s not something that can be an in-office repair – such as replacing the gasket, because it’s leaking and it’s not achieving the pressure – and the autoclave has to go out to the service technician, [the] CDC has very specific guidance on what to do after a sterilizer failure. Before you put that sterilizer back into service sterilizing instruments, it must pass three spore tests. So, you’ve got to run 3 cycles and have it pass three spore tests before putting back into service. And that’s where the office needs to have some immediate readout validation for those spore tests.”
It’s important to note that a piece of equipment being down doesn’t always mean that the machine is broken. Products used in the sterilization process must be current and usable.
“That’s one of our misconceptions,” Dorst says. “The office might buy a large quantity of pouches. Maybe the manufacturer or distributor had a special on them. I know I’ve had some clients that, in years past when they went to the big regional dental meeting in their area, manufacturers were all having specials, and they would buy a year’s supply and put those on the shelf in their storage room. So, of course they’ve got to have adequate storage, and that may not be in the climate-controlled area of their office. It could be in an attic or a basement, and storage of products for sterilization and disinfection purposes does need to be in a climate-controlled area, because extreme heat, high moisture, extreme cold can be detrimental to those chemical indicators, autoclave tape, CSR wrap and pouches.
“I learned this through first-person experience when I was working with a sterilization client,” she continues. “We were ready to go live with their new sterilization room, they could not order and receive shipment quickly enough for some unique size pouches. I happened to have a few of them that I kept in a storage closet that I use for educating during live seminars. And so, I just took a box of those to the sterilization ‘Go Live’ training, but didn’t check the expiration date. So, during the sterilization training, we loaded up these unique size pouches, ran them through a cycle. And, when I opened the autoclave door, the internal and the external indicators had not changed color. I was shocked. I thought something was possibly wrong with the sterilizer. And, I immediately called the manufacturer. And they said, ‘Jackie, was that a box of pouches that you had in your storage room, what’s the expiration date?’ I looked at the box and sure enough, it was over a year past the expiration date. They said, ‘Yes, those chemical indicators or integrators that are used on our pouches have a shelf life. If the pouches are beyond the shelf life, then the chemical indicators might not change color’. You might think you have a sterilizer failure when, in essence, if you were using fresh materials that were within their shelf life, the chemical indicators will change color, providing the visual indication that the sterilizer is working properly, and the instrument pack has been sterilized. So, it’s important to know what’s the shelf life on your sterilization products, as well as your disinfectant products, and your cold-sterilization solution. If you use disinfectant wipes, you might have some beyond their expiration point.”
Ideally, practices will keep up on proper maintenance and never have a critical equipment malfunction. However, it can happen and knowing how to proceed and having contingency plans can help keep the practice open and productive.