"Just let it flow"

May 19, 2014
One of the most common areas in a dental office to address during one of our mock audits is the central sterilization area.

By Olivia Wann, RDA, JD

Let it flow…Just let it flow. One of the most common areas in a dental office to address during one of our mock audits is the central sterilization area. According to the CDC, we designate a central processing area for 1) receiving, cleaning, and decontamination; 2) preparation and packaging; 3) sterilization; and 4) storage.

It is challenging for dental practices to accomplish this flow in the sterilization area if old routine habits are hard to break or if the space is small. Whether the sterilization area is small or spacious, however, our goal is to avoid cross-contamination and promote efficiency.

To launch the effort to improve this area of infection control, let us begin by concluding patient care and breaking down the treatment room:

First, remove disposable, contaminated materials in the operatory. Dispose of contaminated sharps such as needles, blades, orthodontic bands, orthodontic wires, and burs chairside. There is no need to carry these items to the sterilization area and risk an injury. Thus, sharps containers are located in each treatment room, near the hazard.

Speaking of sharps containers, a number of dental offices are reluctant to place sharps containers in the operatories out of concern that it diminishes the esthetics of the room. However, according to OSHA, the location of the sharps containers shall be at the point of use (i.e., each operatory). NIOSH suggests that the container be placed in a visible location, within easy horizontal reach and below eye level. The containers should be placed away from any obstructed areas such as near doors, under sinks, near light switches, etc.

In reference to instrument processing, OSAP says "all procedures must be performed correctly every time to make sure that items are processed properly and in the safest way possible." Thus, in order to perform such procedures correctly every time, it is helpful to implement standard operating procedures for infection control. We recommend that each practice obtain a copy of OSAP's publication, From Policy to Practice: OSAP's Guide to the Guidelines.

Once the disposable contaminated sharps are disposed of, we safely remove the reusable contaminated sharps -- instruments. When handling contaminated instruments, wear appropriate personal protective equipment such as puncture-resistant utility gloves and face/eye protection.

Busy, high volume practices may find it helpful to utilize a holding solution comprised of detergent or enzymatic cleaner if automatic debridement cannot be accomplished for a length of time. This will help prevent debris such as blood from "sticking" to the instruments. Place the holding solution in the "dirty" area.

Automatic cleaning is preferred over hand scrubbing. Never presoak dirty instruments in a high-level disinfectant. Glutaraldehyde (an ingredient in sterilant/high-level disinfectant) makes it more difficult to get debris off of the instruments. In addition, it is a toxic chemical and is not designed for use as a precleaner.

Proceed with the ultrasonic or the FDA-approved dental instrument washer. Run the ultrasonic with its lid in place to avoid cross-contamination via droplets and aerosols. Be sure to change the ultrasonic detergent at least daily, or more often if necessary.

Inspect the instruments and arrange into sets. This somewhat time-consuming step is not necessary if you are utilizing sterilization cassettes such as Hu-Friedy's Instrument Management System (IMS). When using IMS, the instruments are put back into place in the cassette during the procedure, saving valuable time and protecting the instruments from damage or loss.

After the cassette and instruments are dry, you are now ready to package. Designate a space for this step whether you are wrapping cassettes or using pouches. Seal pouches carefully and make certain instruments are not poking out. Package hinged instruments in the open position.

Place a chemical indicator on the inside of each package. If the internal indicator is not visible from the outside, also place an exterior chemical indicator on the package. Label and date the packages.

Moving on in our flow, we are now ready for sterilization.

Follow manufacturer's instructions for biological monitoring, heat sterilization, and the maintenance of the unit (such as replacement of seals, cleaning the unit, etc.). The CDC Guidelines recommend weekly biological monitoring unless sterilizing an implantable device, which requires biological monitoring with every load. When removing the instruments from the sterilizer, make certain the trays or contents are not placed in the "dirty" area. This may be especially challenging for small, confined spaces. Allow the instrument packs to dry and cool before handling. If the sterilizer is at the farthest end of the flow, consider placing the pouches or wrapped cassettes in closed cabinets above the sterilizer.

Do not use sterilized packs if the indicators failed. Do not remove the packaging material until point of use to prevent contamination. Prior to using the packs, carefully inspect to assure that the pack is dry and the packaging not compromised. Keep in mind that damp packages are not considered sterile.

Analyze your sterilization flow and determine if improvements can be made to promote greater efficiency and eliminate cross-contamination.

OLIVIA WANN, RDA, JD, attended Tennessee Technology Center as an RDA and earned a bachelor of science degree in health-care administration from Saint Joseph’s College. She graduated from the Nashville School of Law with a doctorate in jurisprudence and is licensed to practice law in Tennessee. In 2000, she founded Modern Practice Solutions, which is dedicated to the compliance issues of dental practices. For more information visit www.modernpracticesol.com or send an email to [email protected].

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