Easi-Sterilise Standard Operating Procedures

1
Easi-Sterilise Standard Operating Procedures

• Introduction
• Section 1
• Cleaning Procedures

2
Housekeeping

• Fire exits
• Bathrooms
• Mobile phones
• Tea and coffee
• Respect

3
(No Transcript)
4
Why are we here?

• Patient and staff safety
• Directives from QH EMT for rapid implementation
  of education and training following incidents
• Implementing a continuous quality improvement
  program
• Targeting training needs not targeting
  individuals
• Acknowledge an absence in effective communication
  when changes are made
• To build on current level of knowledge in light
  of ever changing technology, standards,
  guidelines, advisories and legislation

5
QH Commitment

• Is to
• Appropriately train and skill staff
• Provide information and resources so that
  step-by-step quality processes are consistently
  followed
• Assist in identifying gaps in knowledge and
  provide opportunities for improvement

6
Aim of this workshop

• Provide participants with strategies to implement
  the SOPs and WSAs locally by improving and
  standardising knowledge on
• Pre-cleaning
• Cleaning
• Drying instruments
• Packaging
• Sterilising
• Storage
• Annual performance qualification/validation of
  the sterilisation process

7
SOPs WSAs

• To assist Oral Health facilities operationalise
  QH policy and guidelines
• A resource for staff
• Update and supersede the OH Critical Instrument
  Tracking (2003)
• A framework to assist staff identify competence
  and areas where education and improvement may be
  needed
• A resource to identify opportunities for
  improvement within the department that will
  require further education and training

8
(No Transcript)
9
Section 1

• Cleaning Procedures

10
1.1 Standard Precautions

• Standard precautions are applied as a first-line
  approach to infection control. These form the
  basis for your decision-making and practice.
  Standard precautions are a set of guidelines
  based on the assumption that all blood and body
  fluids are potentially infectious.

11
1.1 Standard Precautions

• In the context of sterilising practice and ALL
  the Standard Operating Procedures, standard
  precautions include
• Hand Hygiene
• Hand cream approved by infection control not
  in packing area
• Personal Protective Equipment
• Gloves
• Face shields, hair protection, safety glasses and
  masks
• Fluid resistant gowns/aprons
• OHS Requirements

12
1.2 Soiled Pickup Collection

• Standard Precautions - PPE
• Contaminated items - dedicated collection
  trolley/cart
• Keep instrument sets together
• Follow the designated route with trolley (OHS)
• Collection containers are
• puncture-resistant
• leak-proof and made of either plastic or metal
• with a lid or liner that can be closed

13
1.2 Soiled Pickup Collection

• Cleaned items must be dried prior to transport
• Reusable instruments cassettes and single items
  placed into designated transport containers
• Secure single loose items
• Donts
• Place heavy instruments on light instruments
• Lift above shoulder height
• Containers should not exceed 10 kgs

14
Containers for Transport from Surgery

• with a lid
• easily cleaned
• puncture and leak proof
• kept in a clean, dry condition
• not overloaded
• carefully packed
• sharps recognised
• facing same direction

15
1.3 Sorting Prior To Cleaning

• Instruments and items sorted by
• Type
• Method of cleaning e.g. Manual , ultrasonic,
• Instruments and items are checked for
• Completeness
• Defects
• Sharps or blades that have not been removed
• Heavily soiled items
• Single use only items are not to be returned for
  reprocessing
• Report concerns to supervisor

16
Cleaning

• Cleaning removes organic and inorganic soil,
  blood, fats etc which contain pathogenic
  micro-organisms
• Cleaning minimises contamination levels of
  bioburden (number of micro-organisms) prior to
  sterilisation
• For sterilisation to occur the aim is to have a
  low number of micro-organisms present on
  instruments

17
Cleaning

• Steam will not penetrate contamination left on
  instruments
• If the item is not clean it wont be sterilised

18
1.4 Chemical Detergent Mixtures

• Breaking down and removal of
• Blood, proteins and debris (organic soils)
• Medicaments and chemicals (inorganic soils)
• Breaks water tension surfactant
• Keeps the soils suspended in the water
• Must be an instrument detergent. DO NOT use
  household type
• Compatible with instruments and equipment
• Material Safety Data Sheets (MSDS) ChemAlert
• Appropriate storage requirements

19
1.4 Chemical Detergent Mixtures

• Manual cleaning agents
• Mild alkaline instrument detergent - optimal pH
  8.0 -10.8
• Low foaming properties
• Non-corrosive
• Non-toxic
• Non-abrasive
• Free rinsing
• Bio-degradable
• Preferably liquid
• Use and rate of concentration as per
  manufactures instructions

20
1.4 Chemical Detergent Mixtures

• Mechanical cleaning agents
• Mechanical washer manufacturers requirements
• e.g ultrasonic or washer/disinfector
• May be stronger alkaline pH range 8.0-11.5
• Biodegradable
• Nonabrasive
• Low foaming
• Free rinsing
• Preferably liquid
• Use and rate of concentration as per
  manufactures instructions

21
1.4 Chemical Detergent Mixtures

• Enzymatic Cleaners
• Includes enzyme pre cleaners and enzymatic
  detergents

22
1.4 Chemical Detergent Mixtures

• Drying Agents/Rinse Aids Washer disinfectors
• Surfactants that wet the final rinse water
• Automatically dosed into the final rinse water
• Spreads evenly over a surface instead of beading
• Beaded water leaves mineral salts
• Not as effective on plastics
• Load instruments and metals on the top racks with
  plastics on the bottom
• Plastics on edge to allow drainage

23
1.4 Chemical Detergent Mixtures

• Acid Base Agents
• Only on stainless steel surfaces
• Only intermittently descaling or destaining
• Dissimilar instruments should not processed at
  the same time
• Mix the agent as per manufacturers instructions
• Only mix when required and discard at end of the
  day
• OHS -Chemical manufactures instructions ,
  including safety precautions, dilution and
  instrument compatibility
• OHS - Rubber or nitrile gloves

24
1.4 Chemical Detergent Mixtures

• Lubricants
• Water miscible able to mix with water
• Compatible with the sterilizing agent
• As per manufacturers instructions
• Instrument stiffness needs to be investigated
• Lubrication used intermittently
• Routine use heavy contamination

25
1.5 Pre Cleaning

• Pre cleaning (initial cleaning) allows for the
  removal of visible blood, body fluids and debris
  from items prior to cleaning (definitive
  cleaning). Pre cleaning shall be undertaken as
  soon as possible (e.g. during and post procedure
  chairside).
• If blood, proteins and other debris are allowed
  to dry or remain in crevices and joints, the
  instruments become very difficult to clean and
  are prone to stiffness and accelerated corrosion.

26
1.5 Pre Cleaning

• Pre cleaning can be performed by methods such as
  dry wiping, damp wiping or use of a commercially
  available single use only instrument sponge
• Place the dry wipe, damp wipe or sponge on the
  bracket table and carefully wipe the instrument
  across the material

27
1.5 Pre Cleaning

• Rinsing removes excess blood and debris
• Prevents blood and debris drying on items
• As soon as possible - post procedure
• Reduces bioburden - micro-organisms will multiply
  rapidly
• Use warm water
• hot water coagulates protein
• cold water - congeals fats

28
1.6 Hand Cleaning For Immersible Items

• Automated cleaning of instruments is the
  preferred practice, but not always feasible
• Identify instruments that cannot be immersed
  under water for manual cleaning
• Two dedicated sinks large, deep enough for
  practical use
• Separate hand washing facility

29
1.6 Hand Cleaning For Immersible Items

• Warm water potable (drinkable)
• Instrument brushes various sizes
• Disposable low - lint cloth
• Suitable instrument detergent Ph 8
• Pressure equipment
• High pressure water
• Air pressure
• Disposable Syringe
• Non abrasive pad

30
Double Sink Operation

• The first sink is to be always used for the
  initial rinse of instruments only and does not
  need to be cleaned between use.
• The second sink is to be used for the cleaning
  and the final rinse of instruments and only needs
  to be cleaned between these two activities if the
  instrument cleaning water is discoloured or
  cloudy.
• NB all sinks must be cleaned at the end of the
  day

31
Single Sink Operation

• The sink is to be cleaned with a detergent
  impregnated wipe between the first rinse of the
  instruments and the filling of the sink for
  cleaning the instruments.
• Following cleaning of the instruments and before
  the final rinse the sink only needs to be cleaned
  with a detergent impregnated wipe if the cleaning
  water is discoloured or cloudy.
• NB all sinks must be cleaned at the end of the
  day,

32
1.6 Hand Cleaning For Immersible Items

• Standard Precautions
• Heavy duty gloves PPE
• Initial Rinse - rinse instruments under warm
  running water
• Fill sink correct ratio of warm water and
  suitable detergent
• Identify instruments that require manual cleaning
• Disassemble and open items
• Inspect for damage or parts missing
• Immediately notify the supervisor and contact
  user area

33
1.6 Hand Cleaning For Immersible Items

• Limit the generation of aerosols
• Holding item low in the sink under the water line
• Apply adequate friction
• Visualise item under the water line
• Prevent against sharps injury and damage to the
  instrument
• Final rinse Rinse thoroughly under hot running
  water
• Check that the item is clean LOOK and CHECK
• Use a magnifying glass if necessary

34
1.6 Hand Cleaning - Final Rinsing

• Final rinsing facilitates the drying of item
• Use warm water
• Mechanical washer disinfectors use hot water
• Removes chemical residues
• Tissue irritation
• Instrument damage
• If a demineralised/reverse osmosis water system
  is installed, rinse with demineralised/ reverse
  osmosis filtered water.

35
1.6 Hand Cleaning For Immersible Items

• Cleaning brushes
• Check no broken bristles or requires replacing
• Kept free of visible debris during, after use and
  before reuse
• Single or limited use cleaning materials
• Single use, non-abrasive cleaning brushes are
  disposed of at the end of the day.
• Reusable cleaning brushes are to be thermally
  disinfected at the end of the day and stored dry.

36
Unsuitable Cleaning Agents or Equipment

• steel wool or other harsh abrasives
• cleaning powders
• excessive temperatures
• dangerous chemicals
• corrosive chemicals

37
1.6 Hand Cleaning For Immersible Items

• Flush, Brush and Flush all lumen items
• Flush lumen with water
• Wet bristles of correct size instrument brush
• Pass instrument brush through the lumen and rinse
  debris off brush tip in an appropriate cleaning
  solution
• Withdraw brush
• Flush through with running hot water 
• Repeat until clean

38
1.6 Hand Cleaning For Immersible Items

• Drying As per manufacturers instructions
• Drying cabinet
• Disposable low-lint cloth for hose, battery and
  external parts
• Air pressure gun (for removal of excess moisture)
• Disposable syringe
•  

39
1.6 Hand Cleaning For Immersible Items

• Problems associated with incorrect drying
• Items should NOT be air dried/ dripped dry
• Good conditions micro-organisms multiply in
  20-30 minutes
• Wet packaging result in unsterile item
• Can cause rusting, corrosion, pitting to the item

40
1.7 Hand Cleaning For Non-immersible Items

• For those items that are unable to be submerged
  under water
• Some items e.g surgical handpieces and
  attachments, may need hoses or caps attached to
  prevent water entering delicate parts

41
1.7 Hand Cleaning For Non-immersible Items

• Initial rinse - Some items may be gently rinsed
  with warm water to remove gross soil as per
  manufacturers instructions.
• Initial rinse - Some items may be rinsed using a
  low lint cloth immersed in water if the item
  cannot be placed under gently running water
• Fill sink correct ratio of warm water and
  suitable detergent
• Items are wiped using a clean cloth immersed in
  the clean, warm water with detergent added
• The cloth is squeezed (wrung out) to prevent
  water entering the instrument, it is damp only,
  and not dripping wet

42
1.7 Hand Cleaning For Non-immersible Items

• The impregnated damp cloth is rubbed over the
  item
• May need to be repeated depending extent of
  soiling
• Handpieces that cannot be immersed in water
  follow the manufacturers instructions
• Non-immersible cannulated items - the
  manufacturers instructions must be adhered to in
  relation to flushing and brushing

43
1.7 Hand Cleaning For Non-immersible Items

• Following washing the detergent must be removed
• FINAL RINSE - Using a damp clean low lint cloth
  (that has not been in contact with detergent),
  wipe over the item to remove the detergent. Note
  if a demineralised/reverse osmosis water system
  is installed, rinse with demineralised/ reverse
  osmosis filtered water
• These steps may need to be repeated to remove all
  traces of detergent (Dry as per instructions in
  SOP 1.6 immersible item)

44
Handpieces

• handpieces
• outside surfaces cleaned using detergent wipe,
• rinsed by wiping
• dried
• slow speed motors
• outside surfaces cleaned using detergent wipe,
• rinsed by wiping,
• dried
• lubricated (manually or automatic) may need
  special adaptors
• Dried, wrapped processed in a wrapped cycle

45
Special adaptors may be needed
46
Special adaptors may be needed
Ideally, handpieces and slow speed motors are
cleaned and lubricated using mechanised cleaning
equipment
47
Special adaptors may be needed
48
1.8 Ultrasonic Cleaner

• Purpose
• Ultrasonic cleaning is a form of mechanical
  cleaning that uses high frequency ultrasonic
  waves (cavitation) that dislodges fine particles
  from the surfaces of instruments.

49
Ultrasonic cleaning is an effective cleaning
method for instruments prior to the reprocessing
50
1.8 Ultrasonic Cleaner

• Minimises manual cleaning
• Does not disinfect instruments
• Remove debris using cavitation (sound waves)
• Detergent as per manufacturers instructions
• Requires degassing before use
• Rinsing after use (if no further
  washer/disinfector processing)
• OHS do not immerse hands when operating
• OHS aerosols use lid when operating
• OHS noise use lid hearing protection
• OHS dry hands when handling electrical leads
  and turning on or off at power point.

51
1.8 Ultrasonic Cleaner

• Follow manufacturers instructions
• Newer models may have different requirements
• Fill the tank with water
• (may be cold or warm follow manufacturers
  instructions)
• Then add the specified amount of detergent
• Degas the water close the lid for recommended
  time
• Lumen instruments undergo manual cleaning first
  (FBF)
• Initial Rinse Rinse all items with warm water
  to remove gross soil before placing into
  designated baskets
• Disassemble and open items

52
1.8 Ultrasonic Cleaner

• Place instruments in basket as per manufacturers
  instructions. Do not overload basket as
  ultrasonic waves will be unable to penetrate the
  soil on the instruments
• Never place items on the floor as transducers
  will be damaged.
• Place delicate or small pieces of items into lock
  down baskets
• Fully submerge the items below the waterline.
• Close lid and operate for recommended time

53
1.8 Ultrasonic Cleaner

• For bench top ultrasonic cleaning, use clean
  gloved hands
• Final Rinse - Thoroughly rinse instruments with
  warm running water
• Lumened items to have excessive moisture removed
  by air pressure gun or disposable syringe
• Dry using a drying cabinet or with a disposable
  low lint cloth

54
1.8 Ultrasonic Cleaner

• EMPTYING AND CLEANING THE MACHINE
• Daily and if solution becomes murky or
  discoloured as cleaning cannot occur in dirty
  solution.
• Routine cleaning of the ultrasonic machine is
  required see
• (SOP 5.9 Routine Cleaning Reprocessing Equipment)

55
1.9 Washer Disinfector Machines

• Batch and continuous type washer disinfectors
  clean and remove bio burden/micro-organisms
  (blood and debris)
• Thermal (high level) disinfection using time at
  temperature final rinse
• Means the cleaning process is verifiable
• Lumened items still require Flush brush Flush
• Unlock and open items
• Use appropriate washer baskets/inserts
• Keep sets together

56
1.9 Washer Disinfector Machines

• Loading
• Lumen instruments have been flushed, brushed and
  flushed
• Use specific washer insert that is required e.g.
  dental handpieces
• Disassembled, unlocked, opened (e.g. forceps,
  needle holders, scissors)
• Ensure parts of disassembled instruments are
  together
• Use disk or tags to identify instrument trays
  when using multiple baskets
• Small/light items placed in lidded basket with
  hold down catch

57
1.9 Washer Disinfector Machines

• Loading
• If using barcode baskets select correct basket
• Load the baskets/racks ensuring they are not
  overcrowded or over opened
• Use a hold down screen
• Hollowware is loaded in a draining position
• Minimise lifting of racks
• Make sure equipment stays in the parameter of the
  rack.
• Select the appropriate cycle for the load

58
1.9 Washer Disinfector Machines

• REPORT IMMEDIATELY
• Cycle parameters not meeting set requirements or
  variations to cycle parameters failed cycles
• Items that appear dirty or stained are returned
  to the cleaning area for recleaning/destaining
• Excess water check the following the machine
  temperature, amount of rinse aid going into the
  machine or the way in which the machine was
  loaded
• Damaged instruments

59
1.10 Washer Disinfector Machines

• Releasing the load and unloading the washer
  disinfector
• Authorising release of the load occurs on
  completion of washer disinfector cycle and prior
  to opening the door.
• Check cycle parameters have been met and print
  out/log (or equivalent) is signed
• Care opening the doors due to heat and moisture
• Inspect load not become dislodged or displaced
• Avoid injury and damaging the equipment/instrument
  s

60
Washer disinfector printout
61
1.9 Washer Disinfector Machines

• UNLOADING continued
• Check for cleanliness
• If machine does not dry - place into drying
  cabinet
• Industrial dry and oil free compressed air used
  to remove excess moisture from lumen instruments.
  
• Only when dry, place instruments onto designated
  work benches to await packing/wrapping

62
1.10 De-staining

• Stains corrosion, pitting or other damage
• Staining can occur
• Chemical incompatibility
• Water quality
• Interaction of alloys in instruments
• Investigate cause

63
1.10 De-staining

• Occupational Health Safety
• PPE
• Acid based de-staining chemicals are a strong
  acid and can cause burns to hands, eyes etc.
• Read and follow the manufacturers instructions
  and precautions.
• Refer to MSDS for first aid instructions

64
1.10 De-staining

• Only use intermittently NOT ROUTINELY
• Check de-staining solution is compatible
• Usually only stainless steel instruments.
• Standard precautions
• Wear protective clothing heavy duty gloves
• Use a container with a good fitting lid
• Strictly follow manufacturers instructions on
  water temperature, chemical ratio and exposure
  time
• Dissimilar instruments not processed at the same
  time

65
1.10 De-staining

• Remove item using gloved hands
• After exposure item re-washed to remove chemical
  residue
• Only mix de-staining solution when required
• Change chemical daily or more often if solution
  discoloured.
• Remove gloves and wash hands.
• Identify and report any patterns of staining

66
1.11 Drying Cabinet

• Purpose
• To dry the cleaned item prior to wrapping and
  packaging and prevent damage that occurs to the
  item if it is left wet.
• Loading
• Unloading
• OH S considerations