By NOEL BRANDON KELSCH, RDHAP
A reader recently wrote, "I have just had it! The sterilization area in our office is a mess! No one wants to take responsibility and we end up arguing about it everyday. What can I do?"
She is not alone. This is an area that the Centers for Disease Control and Prevention and Food and Drug Administration (FDA) has really been focusing on, alerting health-care providers about the importance of safety in this area of the dental practice.
There have been several lapses reported that have impacted the outcome of dental treatment, including the spread of disease. These critical gaps remind us how important each step we take in infection control is. Remember, the sterilization area in the dental practice is core of infection control. It is the area that is set aside for processing, and it must ensure safety for patients and staff. All instrument cleaning, disinfecting, and sterilizing must occur in this area.
It takes a team to make this happen. No one person can do this alone. There are people involved at every point. Each one taking one part of the task makes all the difference.
My suggestion is that you assign, divide, and conquer! Please take the time as a team and look to see if the processes are being followed and assign them to staff.
- Does the office have a well-defined area for sterilization that is divided between unsterile, and sterile. This is a key point. You must train all staff the difference between these areas and never allow cross contamination by putting a clean item in the dirty area, or a dirty item in the clean area.
- Has this area been broken down into receiving, cleaning, and decontamination.
Questions to ask include:
- Are dental instruments and devices cleaned of all visible blood and other contamination before they are sterilized or disinfected?
- Are you using an automated cleaning equipment (such as an ultrasonic cleaner or washer-disinfector) used to remove debris, improve cleaning effectiveness, and decrease worker exposure to blood?
- Does the ultrasonic bath work, and has it been tested lately?
- Are work practice controls (such as a long-handled brush) used to minimize contact with sharp instruments if manual cleaning is necessary?2,3
Questions to ask about preparation and packaging include:
- After cleaning, are critical and semicritical instruments inspected for remaining debris?
- Before sterilization, are instruments and other patient-care items packaged using an FDA-cleared container system or wrap that is compatible with the type of sterilization process used? (Packaging instruments in cassettes or trays before sterilization maintains their sterility after the sterilization cycle.)
- Is an internal chemical indicator built in or placed inside each instrument package prior to sterilization?
- If the internal indicator is not visible from outside the package, is an external indicator affixed to the pack?
- Are packages labeled with the date, and, if multiple sterilizers are used within the facility, which sterilizer used was used? (This simplifies retrieval of processed items in case of a sterilization failure.)2,3,4
Questions to ask about sterilization include:
- Is the sterilizer working properly, and is it FDA approved?
- Do we need another sterilizer?
- Are all instructions for the specific sterilizer being followed completely?
- Is the full cycle including drying (to prevent wicking)?
- Are mechanical, chemical, and biological monitors used according to the manufacturer's instructions to ensure the effectiveness of the sterilization process?
- Is each load monitored with mechanical and chemical indicators?
- Is a chemical indicator placed on the inside of each instrument package to be sterilized?
- Is there an internal chemical indicator and an external chemical indicator? Chemical indicator?
- If mechanical or chemical indicators suggest inadequate processing, are instruments pulled from recirculation, repackaged, and sterilized again with new indicators?
- Are sterilizers monitored at least weekly using a biological indicator and a matching control? (Using both a test and a control indicator from same lot ensures that factors outside of the sterilization process have not affected the spores' ability to be cultured.)
- Is the test indicator placed within an instrument pack and sterilized with a normal load?
- If a spore test comes back positive, are proper troubleshooting procedures implemented? (For a flowchart on managing sterilization failures, visit osap.org.)
- Are sterilization records (mechanical, chemical, and biological) maintained in compliance with state and local regulations?2,3,4
Question to ask about storage include:
- Are sterile items and dental supplies stored in covered or closed cabinets, or containers to minimize the chance of contamination and never left out in sterilization area?
- Are wrapped packages of sterilized instruments examined before they are opened to ensure the packaging (and sterility of the instruments inside) has not been compromised?
- If packaging has been compromised, are the contents recleaned, repacked, and resterilized?
- Does the practice setting use either date ("first in, first out") or event-related storage for wrapped, sterilized instruments and devices? (Both methods are considered acceptable.)2,3,4
- Are single-use disposable items disposed of in the operatory before going to sterilization?
Here's a tip about single use items, which are designed to be used only once. They are not designed to be cleaned, disinfected, or sterilized, and this group of products includes blades, needles, disposable prophylaxis angles, carpules, cups and brushes, evacuator tips, saliva ejectors, and air/water syringe tips.1
Disposal eliminates the chance of cross-contamination, the need for extensive postoperative handling (with a risk of sharps injuries), and exposure to sterilization chemicals. Disposing of all single-use items immediately after treatment limits the risk of sharps injuries. These should be eliminated from the tray as close to the point of use as possible.
Are instruments placed in a covered container before being transferred to sterilization? Instruments need to be placed in a covered container for transportation.
The simplest way to do this is to use a cassette. A cassette will also decrease the handling of instruments, thus decreasing the sharps injuries, keep the instruments from dulling or breaking due to movement in the ultrasonic bath, keep the instruments together and organized eliminating the need to sort after cleaning, and decrease poking through the sterilization pouch. The thing that I love about this system is that it eliminates the number one reason for failed loads-overstuffing the sterilizer.
Has all clinical staff been trained in reprocessing and the sterilization area, including personal protective equipment? Are their responsibilities spelled out and assigned?
Personal protective equipment in sterilization is imperative. The CDC states: "Instruments should be handled as though contaminated until processed through the sterilization cycle (unless the instrument has been processed with a thermal washer/disinfector that has a high-level disinfection cycle). To avoid injury from sharp instruments, personnel should wear puncture-resistant, heavy-duty utility gloves when handling or manually cleaning contaminated instruments and devices. Because splashing is likely to occur, they should also wear a facemask, eye protection or face shield, and gown or jacket. Employees should not reach into trays or containers holding sharp instruments that cannot be seen. To reduce their risk of injury, they should instead remove instruments using forceps or empty them onto a towel."
Are all assurances being adhered to and recorded, including the sterilization log, spore testing, and internal and external indicators for each item?
I think most importantly: Does the office have an assigned infection control coordinator that is overseeing these processes? This person is to oversee the process and procedures in infection control and coordinate compliance and training.
Are you having annually the federally required OSHA training that includes the use of the sterilization area? The CDC and OSAP websites both offer materials that can be reviewed during the OSHA training.
It takes a team to make sterilization flow. There are people involved at every point. Reviewing the process, assigning the tasks and each person taking responsibility can makes all the difference. RDH
1. Martin MV. New Concepts in Cross-Infection Control in Dentistry. Brit Dent J. June 8, 1990.
4. OSAP: From Policy to Practice resources on its website.
NOEL BRANDON KELSCH, RDHAP, is a syndicated columnist, writer, speaker, and cartoonist. She serves on the editorial review committee for the Organization for Safety, Asepsis and Prevention newsletter and has received many national awards. Kelsch owns her dental hygiene practice that focuses on access to care for all and helps facilitate the Simi Valley Free Dental Clinic. She has devoted much of her 35 years in dentistry to educating people about the devastating effects of methamphetamines and drug use. She is a past president of the California Dental Hygienists' Association.