The Compliance Divas Podcast
Our podcast covers current topics such as infection prevention and control, OSHA and HIPAA compliance for dentistry. We discuss the latest regulatory information, answer frequently asked questions and give suggestions for dental practices to make compliance easy and sustainable. The Compliance Divas are a trusted source for consistent, accurate information based upon current guidelines, standards, science, and recommendations.
The Compliance Divas Podcast
#220 Instrument Cleaning: The Essential First Step in Effective Sterilization
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If dental instruments aren’t thoroughly cleaned, they can’t be properly sterilized. In this episode, Mary and Linda discuss why effective instrument cleaning is essential for successful sterilization and share best practices to ensure your instruments are truly clean and ready for safe use.
Resources:
- CDC Guideline for Disinfection and Sterilization in Healthcare Facilities - section on Cleaning: https://bit.ly/49gllzn
- HuFriedy Group - 6 Critical Steps for Cleaning and Protecting Your Dental Instruments https://www.hufriedygroup.com/en/blog/6-critical-steps-cleaning-and-protecting-your-dental-instruments
- American Dental Association (ADA) Caring for Dental Instruments https://jada.ada.org/action/showPdf?pii=S0002-8177%2821%2900785-6
Welcome.
SPEAKER_02I'm Leslie Cannum.
SPEAKER_00I'm Mary Gavoni. I'm Linda Harvey. I'm Olivia Juan. And together we are the Compliance Divas.
SPEAKER_02Welcome to the Compliance Divas Podcast. This is Mary Gavone. I'll be the moderator for this episode along with our diva Linda Harvey. Our topic today is how do we get our instruments clean? Because it's a critical step in reprocessing and making those instruments safe for reuse. We know that all the debris needs to be removed from those instruments prior to packaging the instruments and getting them into the sterilizer. So we're going to discuss some of the important tips we have to clean the instruments, avoid having to routinely hand scrub, but making sure you get all the debris off the instruments. So Linda, start us off talking about what does OSHA say about safely handling contaminated instruments and cleaning them?
SPEAKER_01Mary, you know, cleaning instruments is still one of the most debated things in a dental practice, you know, especially when it comes to hand scrubbing. Many times, particularly dental assistants throughout different procedures when there's extra blood or the procedure has been extra bloody, they feel like they need to hand scrub. And sometimes team members feel like they need to hand scrub anyway before it goes into the ultrasonic, but we know the mechanical and we'll talk about the ultrasonic in a few minutes. But if it's set up properly and we have a good solution, it is the solution, or the using that word as a pun now, it is that is the solution for pre-cleaning instruments properly before they go into the sterilizer. OSHA has some things to say when it comes to employee safety, as we know. So one thing to bear in mind is that OSHA does not approve us hand scrubbing and dentistry because it raises the risk of being cut or punctured or scraped with a contaminated instrument. And we all know how and I'll say this with love, little teams just don't really prefer to wear the heavy utility gloves like we should, which gives them more protection. So if you're not using the heavy utility glove and you're hand scrubbing, you're putting yourself at greater risk. Even if you are, there still could be some other risk, and the risk of spray and splatter to your face is a risk, for example. So you know that we're when we run through sterilization, it's like a drive-by sometimes. It's like quick, drop the instruments here, do this, and get back to the chair, clean up and get the next patient seated. So we just need to have those a couple of extra seconds to be able to position, and I'm using the word position, meaning organize the instruments, organize the process so you get the first step of pre-cleaning done properly. Because Mary, we all know if the instruments aren't pre-cleaned properly, there's no way they're sterilized. So hand scrubbing is really not the best practice. That changed years ago, and it would be considered an OSHA violation to be in sterilization and hand scrubbing. You're right, Linda.
SPEAKER_02It does pose a risk, but there may be some isolated incidents where maybe one instrument didn't get all the debris removed. And so we can selectively hand scrub those. But what we're talking about is routine hand scrubbing of all the instruments, flinging the debris around, potentially putting our hands at risk. And that's not the best thing to do.
SPEAKER_01And putting your eyes at risk. So I totally agree. I mean, selective hand scrubbing has been really the more practice lately in more recent years. And I think there's some ways they can even eliminate that, Mary, if we kind of toss out a couple of suggestions today. One would be during the procedure to have even an alcohol soaked gauze nearby. So and have it positioned or set up so that all you have to do is quickly swipe the instrument, whether it's a spatula or a curette with you know calculus and blood on it quickly, because you should not use two hands when you're wiping an instrument at chair side, much less scrubbing it in sterilization, because definitely with an exam glove only, you're setting yourself up for potential injury. What other thoughts do you have about maybe trying to pre-clean or you know, I'll use the word pre-clean, an instrument chair side.
SPEAKER_02Absolutely. Well, one thought back on getting the instruments cleaned, the ultrasonic, of course, is not the only alternative that we have. Some practices do have an instrument washer which automates that process, but I would caution folks from thinking that they could just use a household dishwasher in their offices for cleaning instruments for a number of reasons. One is it's not an FDA cleared medical device and you're using it in conjunction with a very critical process. So that's actually in a violation of FDA laws. The other is that in an in a dishwasher, you can't use any kind of enzymatic cleaner. You have to use dishwasher detergent, which has bleach in it, which can harm your instruments. But if you don't have an instrument washer, you're relying on that ultrasonic cleaner, then think about what Linda said about trying to get cement, especially, or composite materials off those instrument tips before that material sets up. But if you have blood on instruments and you're not able to get them off, maybe on surgical instruments and so forth, you can use pre-soaks. You can pre-soak your instruments in enzymatic cleaner in a separate container and it will help dissolve the blood. And there are a couple of pre-cleaners out on the market. There are a couple that are foam-based cleaners that will help to break up that blood. But there also is a gel cleaner called Enzymax that really adheres to the instruments, and you can watch it just break up that blood on those instruments. So you can pre-treat those instruments before they even go in the ultrasonic to make sure you get all the blood and debris. But cements are a different story. Linda.
SPEAKER_01Mary, I love the idea of using the pre-soak, the gel particularly. And one thing I've often recommended is when you're in the operatory and you're taking that cassette or maybe the loose instruments and you're putting them in your OSHA-compliant transport container, that you could have a spray under the sink along with your sharps containers and your disinfectant wipes and spray there really quick. And then you start the process of the bio burden breaking down. That could be another workflow approach, if you will, or do it in sterilization, depending on how it works for someone's personal preference, right?
SPEAKER_02Oh, I love it. That's a great idea. Get them already cleaning before you get there, and it just helps you to be that much more efficient. And another thing, when you were talking about having either an alcohol gauze or something to clean instruments off as you go, I have seen a number of hygienists actually take a Dappen dish and put some hydrogen peroxide in it. So when they are doing an SRP and they've got a fair amount of bleeding, they can just swish the tip of their instrument around in that hydrogen peroxide and it will help dissolve the blood and keep it from coagulating and drying out on those instruments. But one of the biggest things that I see, especially in times where we're shorthanded, is sometimes the instruments are stacking up in the instrument sterilization area where we're not getting them into the ultrasonic bath right away. The longer they sit on a countertop with debris blood, especially on them, the harder it is to get them clean. Once that blood dries on there, it's much more difficult to get them clean. So it takes about as much time to drop a cassette of instruments or drop a handful of instruments into the ultrasonic cleaner as it does to set them on the counter and walk away. So go one step further, get them in the solution or get them in a pre-soak so that you don't end up having to go back. But always remember how important it is to inspect those instruments when you are rinsing them, when you get them out of the ultrasonic. Linda, talk a little bit about the types of ultrasonic solutions because there's a bunch of products out there. Is there a particular class of products that's best for cleaning instruments?
SPEAKER_01Mary, I'm looking forward to talking about ultrasonic solutions because this is one of our hot buttons, I know. So Mary, I'd like to step back just a second because when you addressed busy offices where instruments are piling up and the importance of getting them into the ultrasonic, so what happens on a busy day in a practice where your intention is to get the instruments that you brought in into the ultrasonic, but it's already full. And now you're looking at your schedule and you're starting to have like a minor anxiety attack, or maybe a major anxiety attack, depending on how the day is going. And you want you now you have to get the instruments out before you can put them in. So I don't believe in drive-bys and sterilization at all. You don't just bring your instruments in and throw them into the ultrasonic because I actually have a picture, Mary, of a practice that they were doing that. And when I lifted the lid to check the ultrasonic, of course it was not turned on, it was turned off. I saw a cassette half sticking out of the solution. So things were not being, and that and the items on the very bottom don't get extra clean. You when you and I'll talk about why in just a minute. So it's important to look at the process as a team and say when when anybody walks into sterilization, if there's a step that's backlogged, then you need the grace from your doctor or the hygienist needs to let somebody know that, yeah, I need to, you know, this needs because most everybody has a walkie-talkie, the radios, and they can let somebody know, hey, I need extra 30 seconds or I need two more minutes in sterilization. So that way the front office team can let the patient know, which is just a few minutes, we're preparing the room for you. So, you know, they understand why it maybe took an extra minute or two. But you've got to keep moving the sterilization process forward and not be a blocker when you come in.
SPEAKER_02So communication plays a part in instrument sterilization.
SPEAKER_01Oh, Mary, what a broad brilliant idea. Yes, communication plays a part. We totally agree with that. So circling back to your question then on ultrasonic solutions, the solution that you purchased or the product that you purchased is so very important because there's a gamut of products on the market, not choosing by price only and not looking for just an inexpensive house brand that may or may not be really effective. And there's a couple that I really like. The research comes to the top of my list as one that's really good for cleaning the instruments. And when you use different products in your practice, you'll see the difference in how the handles look. You will notice that they look shinier, they look cleaner, and you'll be surprised at how dirty your ultrasonic solution will be when you switch products to a really top-notch product. So I would say I know budgets are tight, and we're always looking for places to conserve a few pennies or dollars here and there. But do evaluate the products that you purchase and don't just buy them, just like anything else, whether it's a disinfectant wipe or any other product in the office, we're not buying on price alone. We're buying on what this product can do for you, how it will make the instruments clean, and how it will protect our patients ultimately. Mary, I want to say a few things about what causes an ultrasonic not to work properly. So let's let's talk about that because we just gave tribute to and recognize that it can be crazy busy in a dental practice. If the ultrasonic is overloaded, the instruments aren't being pre-cleaned properly. Much like the same analogy of an overflowing sterilizer when you open the door and the instruments are practically falling out at you because you've crammed too many instruments into a sterilizer and you wonder why they're coming out wet and so forth, or colors on the packages aren't turning. So too many instruments in the ultrasonic solution can cause it not to work properly. Not having the proper dilution of the solution or product that you bought is another meaning. Not having enough water, not knowing where the fill line is. And Mary, I don't know about you, but I have seen instances where the directions, the IFU instructions for use on the ultrasonic product, whether it's a tablet or solution, don't match with what the ultrasonic device says. And they don't match in the terms of how they're calculating volume. One will talk about gallons and another will talk about ounces or some other, and you have to do a conversion. So you do have to know that it's not just one tablet if you fill it here and two tablets. If make sure you you know why you're doing what you're doing in the practice, and it makes sense. But I've also noticed that when whether they're using an ultrasonic bath or whether they're using an automated washer, that if either device needs repair and it's not working properly, you cannot use a disinfectant wipe to pre-clean the instruments before they go into the autoclave. I don't care what the disinfectant wipe is, or nor can you use alcohol soap gauze. You cannot pre-clean those ethically or legally and consider them prepared to go into an autoclave device. And it's all those things are actually constitute a violation of the State Dental Practice Act. And Mary, I know you and I have both read a lot of State Dental Practice Acts over the years, and using a commercial, I'm gonna say over-the-counter dishwasher in a dental practice is a violation of most every State Dental Practice Act.
SPEAKER_02But there are equipment reps who are designing sterilization areas that are recommending that and they sell it on a particular brand. The merits of it have a sanitizing cycle. And so the instruments come out clean, they come out sanitized. And in what struck me in your discussion about the type of ultrasonic solution you use, keep in mind that it's not just getting debris off of instruments, which of course we want it to do, but is it protecting your instruments? Does it have a rust inhibitor? Some have triple or quadruple enzyme components in them. So they work on different kinds of organic debris to get them clean. So yeah. And again, if you use a dishwasher, you have to use, if you want to use any kind of cleaner, it has to be dishwasher. So it's not compatible. And I would guess that the instrument manufacturers out there would be voiding warranties on instruments if they know that your instruments are going through the dishwasher.
SPEAKER_01And Mary, and I hear what you're saying about you know, certain brands of commercial dishwashers, maybe sanitized dishes. But when you think about it, it might and that's fine for home use because our our silverware, our cups, our plates, they don't have blood and debris on them from double procedures. They just have normal eating, normal work, no food. And so maybe at most our forks and spoons have saliva on them, okay? But they don't have the blood and debris. So this is it's not even any uh apples stapples anywhere along the line.
SPEAKER_02No, it's not. But the pr there's a big price differential in that appeals. It appeals to a lot of practices. Now, if you're hearing what Linda said before about not overloading your sterilizer, making sure you're using your solution correctly, making sure you're running the appropriate cycle time and so forth, but your instruments still aren't getting clean, then something may be wrong with that ultrasonic. The cavitation action in that unit may not be working, which is what helps to dissolve or knock off the debris from the instruments. So we will put in the show notes directions to do a foil test to test your ultrasonic unit. And I always recommend that folks do it on a monthly or quarterly basis, depending on how new their their unit is. The older the unit, the more frequently I would test it. And then you can know if your ultrasonic is actually doing its job. But your first indicator would be that your instruments just aren't getting as clean as they used to, and it may be time to buy a new one. I know that's a dreaded recommendation right now, but if you're in that situation, go bigger rather than same size or smaller because you want more capacity. And I hear what you said earlier, Linda, about yeah, I want to get my instruments in there right now, and it's already running. What some team members will do was add more instruments in, and that means that the instruments on the top aren't exposed to the cavitation for the right cycle time because they weren't in there for as long as the others. So there's just a whole gamut of issues that that happened because of that. Any final thoughts, Linda?
SPEAKER_01Mary, we talked about some great tips. Let's I think we should be a good idea to recap a couple of the workflow tips that we shared so that way our listeners can take away some ideas to just you know tweak what they're doing. And workflow is always a tweak, looking for how to work smoother and with better outcomes and easier day. So we started off by talking about when the instruments are leaving the operatory. Even before, we started actually talking about during the procedure, right? Where we said try to develop a technique, whether it's the Dappen dish with some hydrogen peroxide, or somehow you are able to secure a wet alcohol so it gauze so that you don't have to use two hands to try and clean it. I could just imagine a dental assistant trying to clean a spatula and hold the sucture at the same time. You can't you have to figure out how to, but like, but as you mentioned, Mary, the restorative materials and the cements don't harden right away. So that gives you a little bit of a breather so that we can come to a point in the procedure where you can do that. That way they're not dried on to the instrument by the time you get to sterilization. We talked about when and how to use the pre-soaks, either in the operatory or in sterilization. And what were some of the other tips that we had, Mary? We talked about that your Dappen dish. I mentioned that, I think.
SPEAKER_02We talked about the type of solution that you use, making sure it is an endomatic solution, using it, diluting it according to the recommendations. And if you have a conflict, as you noted, between what the instructions for use are with the solution versus your ultrasonic unit, then don't hesitate to contact both of the manufacturers with questions about those instructions for use so that you know that you're doing the right thing. And lastly, we talked about the importance of testing your ultrasonic cleaner to make sure that it is actually effective. We just we think because it's still making sound, the jiggler is still making noise. That doesn't mean that it is actually effectively cleaning your instruments. So thanks, Linda, for all of your great tips today. I think this will be very, very helpful to our listeners to just sort of troubleshoot their instrument cleaning process. And one final reminder: once the instruments come out of either an instrument washer or an ultrasonic unit, they need to be inspected to make sure there is no debris on them before they go into the sterilizer. So thank you for joining us for this episode. The compliance divas bring clarity and simplicity to compliance by navigating the regulatory world to keep you on course. If you have questions, you can submit them via email to support at thecompliancedivas.com. We will have numerous resources in the show notes, and we hope that you will join us for another episode. And also scroll down to the end of your podcast app and leave us some comments, feedback, or a rating. Thanks for listening.