Principles And Techniques Of Instrument Processing And Sterilization

Front 1

Autoclave

Back 1

Instrument for sterilization by means of moist heat under pressure

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Biologic indicators

Back 2

Vitals or strips also known as spore tests, that contain harmless bacteria spores used to determine whether sterilization has occurred

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Biologic monitoring

Back 3

Verified sterilization by confirming that all sporeformjng microorganisms have been destroyed

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Chemical vapor sterilization

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Sterilization by means of hot formaldehyde vapours under pressure

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Clean area

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Place where sterilized instruments, fresh disposable supplies and prepared trays are stored

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Contaminated area

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Place where contaminated are brought for precleaning

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Critical instrument

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Item used to penetrate soft tissue or bone

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Dry heat sterilization

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Sterilant by means of dry heated air

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Endospore

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Resistant, dormant structure formed inside of some bacteria that can withstand adverse conditions

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Event related packaging

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Instruments in packages should remain sterile indefinitely unless an event causes them to become contained

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Multi parameter indicators

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Strips placed in packages that change color when exposed to combination of heat, temp, and time: also known as process integrators

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Non critical instruments

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Item that comes in contact with intact skin only

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Process indicators

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Tapes, strips, or tabs with heat sensitive s chemicals that change color when exposed to a certain temp

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Process integrators

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Strips placed in the packages that change color when exposed to combo of heat, temp, and time.

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Safety Data Sheet

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OSHAS newer term for material data sheets. Required for each hazardous chemical in facility

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Semi critical instrument

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Item that comes in contact with oral tissues but does not penetrate soft tissue or bone

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Single parameter indicators

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Tapes, strips, etc with heat sensitive chemicals that change color when exposed to temp

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Ultra sonic cleaner

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Instrument that loosens and removes debris by sound waves traveling through liquid

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Use- life

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Period of time during which a germicidal solution is effective after it has been prepared for use

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Wicking

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Process of microorganisms being drawn through wet or damp paper packaging contaminating instruments inside

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Rankings of evidence

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Category lA - strongly recommended for implementation and strongly supported by well designed experimental,clinical or epidemiological studies

Category B- strongly recommend for implementation and supported by experimental and supported by experimental, clinical, epidemiological studies and a strong rationale

Category lC - required for implementation and mandated be federal or state regulation or standard

Category ll- suggested for implementation and supported by suggestive clinical or epidemiologic studies or theoretical rationale

Unresolved issue - no recommendation

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Classification of patient care items

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3 types:

Critical - touch bone or penetrate soft tissue - very high for disease transmission - sterilization is mandatory

Semi critical - touches mucous membranes but will not touch bone or penetrate soft tissue - moderate rate of disease transmission - sterilization or high level disinfectant

Non critical - contact with only intact skin - very low rate of disease transmission - clean with intermediate to low level disinfectant or basic cleaning

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Instrument processing

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1. Holding (presoaking) facilitates that clean process by preventing debris from drying

2. Precleaning - remove as much of the bioburden as possible to give subsequent sterilization step the best change to work

3. Coercion control, drying, lubrication: reduces damages to instruments and helps ensure proper functioning of the instruments.

4. Packaging: helps maintain sterility of instruments after sterilization and before they are present to subsequent patient

5. Sterilization or high level disinfectant - kills microbes remaining

7. Handling process instruments: helps maintain their sterility of instruments during storage until they are used

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PPE

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To prefer disease agents from previous patient from being transferred to you, then you must use PPE

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7 steps for instrument processing

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1. Transport

2. Clean

3. Package

4. Sterilization

5. Storage

6. Delivery

7. Quality

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Transporting and processing contaminated patient care items

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It’s important to be careful during this time as it’s easy to be contaminated.

- minimized handling of loose contaminated instruments

- clean all visible blood and other contamination’s

- use automated cleaning equipment

- use work practice controls

- wear puncture

- wear PPE

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Instrument processing area/ sterilization area

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Should be centrally located in the office to allow easy acesss from all patient care areas. This minimizes the need to carry contaminated items throughout clean areas.

- should be dedicated to only processing items

- Should be physically separated from the operatories

- should not be part of a common walkway

- no doors or window to the outside

- should have good air circulation

- size should be good to fit all equipment

- proper lighting

- proper water and airline and a vacuum line for flushing high speed handpieces

- deep sink

- no carpet flooring

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Ideal work flood pattern

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Entrance ➡️ contaminated area ➡️ packaging area ➡️ sterilization/storage area ➡️ exit

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Contaminated area

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All soiled instruments brought into contaminated area - initial receiving area where they are held for processing. Use PPE

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Prep and packaging area

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Clean instruments and other dental supplies should be inspected, assembled into sets or trays, and wrapped or placed packages for sterilization. Should consist of counter space and storage space for sterilized instruments, fresh disposal supplies and prepared trays or instrument cassettes

Clean instruments are not sterile. Need to be sterilized before used on a patient

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Precleaning and packaging instruments

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Instruments may be ore cleaned in one of the 3 ways: hand scrubbing, ultra social cleaning or instrumental washing machines

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Holding solution

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If instruments cannot be cleaned immediately after a prosecute is preformed they should be placed in a holding solution to prevent the drying blood and debris on the instruments. Holding solution may be any noncrossive liquid. Dish wash detergent makes a good one. Container must have a lid and be labeled with biohazard and chemical hazards due to contamination and cleaner

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Hand scrubbing

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Least desirable of cleaning instruments because it requires direct hand contact with the contaminated instruments

Precautions:

Googles, clean only two instruments at a time, use long handled brush, keep items above waterline, allow instruments to air dry

Some places prohibit hand scrubbing

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Ultrasonic cleanjnf

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Used to loosen and remove debris from instruments. These cleaners also reduce the risk of hand injury from cuts + punctures. Use PPE and keep a set of tongs nearby to use to remove instruments. Ultrasonic cleaner works by producing sound waves beyond the range of human hearing. Should be processed until visibly clean 5-15 mins

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Ultrasonic cleaning solutions

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Only use solutions specifically formulated for the ultra sonic cleaner. (Enzyme activity)

Labeled with both a chemical and biohazard label

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Care of the ultrasonic cleaner

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Cleaner solution is highly contained and must be discarded at least once a day or sooner if it becomes cloudy. When solution is changed the inside of the pan and lid should be rinsed with water, disinfected, rinsed again and dried. PPE worn

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Testing ultrasonic cleaning

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If you notice instruments not being cleaned after process then unit maybe not be functioning properly. To test if it’s working hold 5x5 tinfoil like a certain vertically half submerged in the fresh unused solution, run for 20 seconds and the gold foil up at light. Should have tiny pebble marks if working.

Front 38

Automated washers/disinfectors

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Look and work like a household dishwasher but need to be approved for dental instruments. Combo of really hot water recirculation and detergents to remove organic material. Automatically dried. Thermal disinfection due to having a level of heat that kills most vegetative microorganisms. Must be wrapped and sterilized before they are used on a patient

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Drying, lubrications, and corrosion control

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Instruments and burs made of carbon steel will rust during stem sterilization. Rust inhibitors such as sodium nitrate or commercial products are available as spray or dip solution to help reduce rust and corrosion.

- dry heat

- chemical vapor sterilization

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Packaging materials and types of sterilization

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Steam sterilization - paper wrap, nylon tubing, paper/peel pouches, thin cloth, wrapped perforated cassettes - NO closed containers, thick cloth, some plastics melt

Dry Heat sterilizes - paper wrap, nylon tube, closed containers - Some paper may char, plastics may melt, use only material approved for dry heat

Unsaturated chemical vapor - paper wrap, plastic/paper peel pouches, wrapped perforated cassettes. Do not use closed containers, do not use cloths, some plastics melts, use only materials approved

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CDC his lines for sterilization of unwrapped instruments

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Thoroughly cleaned and dried before sterilization

Mechanical monitors are checked, and chemical indicators are used for each cycle

Care taken is avoid thermal injury to dental professionals or patients

Items are aseptically transported to the point of use

Critical instruments that were sterilized unwrapped should not be stored unwrapped and semi critical instruments should be used within a short time. Don’t sterilize implantable devices unwrapped

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Advantages and disadvantages of sterilization methods

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Stem autoclave - A - short time, no corrosion, instruments dry quickly. -D- damages some plastics and rubber, requires distilled water, may rust non stainless steel instruments be burs, cannot use closed containers

Unsaturated chemical vapor - A- short time, good penetration of steam, commonly used in dental offices - D- instruments must be dry, damages some plastic and rubbers, requires special solutions, requires good ventilation, cannot sterilize liquids, no closed containers, cloth wrap would absorb chemicals

Dry heat oven type (static air) - A- no corrosion, can use closed containers, items are dry - D - long time, instruments must be pre dried, damages can occur, cannot sterilize liquids

Rapid heat transfer (forced air) - A- very fast, no corrosion, items are dry after cycle - D- damages can occur, instruments must be pre dried, cannot sterilize liquids

Front 43

Flash sterilization

Back 43

Sterilize items and use right away

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Wicking

Back 44

Bacteria from the air contaminates surfaces are drawn through the wet packaging material and contaminates instruments inside

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Typical steam temp in sterilizing cycles

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250 - 30 mins

250 - 15 mins

273- 10 mins

273 - 3 mins

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Results of sterilization errors

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Inadequate instrument cleaning - blood or bodily fluids dry to instruments - organisms may be insulated from sterilizing agents

Improper packing - excessive wrap, not compatible, closed contain in chemical or autoclave - prevents sterilizing to occur, may melt the wrong packaging method or unable to reach inside.

Improper loading is sterilizer - overloading or no separation between packages - increases time to reach proper temp + slow down process, sterilizing may not get everywhere needed

Improper timing - error in timing - insufficient time to sterilize

Improper temp - malfunction or error - insufficient heat to sterilize

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Chemical monitoring

Back 47

Process indicators/single parameter indicators (external) are placed outside of instrument packages before sterilization. Identity when pack has been exposed to a certain temp

Process integrators/ muliparameter integrators - placed inside the package and respond to pressure, temp and time

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Physical monitoring

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Gauges and reading on the sterilizer and recording temps and times

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Biologic monitoring

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Or spore testing

Is the only way to determine whether sterilization has occurs and to continue all bacteria and endospores have been killed. Should happen weekly. It’s a vial or strips of paper that contain harmless bacteria spores that are resist to heat. Two BIS are placed inside and third is set aside to control.

Front 50

Hand piece cleaning

Back 50

Use the flushing technique

And only stem or chemical vapor sterilization (packaged in a bag)