Handling and storing sterile instruments

The act of cleaning, disinfecting, and sterilizing instruments and equipment is just one battle in the war against infection. How the team handles equipment after reprocessing is just as important. Missteps seem to be pervasive, but they are not insurmountable.

Instrument handling

It all starts with how one handles instruments. It is not uncommon to see practices manhandle those instruments. The results can be non-sterile instruments or even damaged equipment.

“There’s a little bit of abuse in the dental world – an abuse of peel pouches, the sterilization paper, plastic pouches,” Peggy Spitzer, dental hygienist and clinical education manager for Certol International says. “The abuse involves, perhaps, putting too many items in the peel pouch and overloading it. That increases the chances of items poking through, creating holes or tears.”

The best practice is to use pouches exactly according to the manufacturer’s instructions.

“Don’t overload it,” Spitzer says. “The items have to have steam reach all the items inside the package to actually sterilize it. So if they’re crammed full, that’s defeating the purpose.”

Careless handling extends to something as seemingly minor as team members touching those instruments without gloved hands.

“Not only do you want to make sure that you're handling sterile items with clean hands, but the less you touch them, the better off,” Joyce Moore, RDH, an infection control consultant and clinical instructor at Bristol Community College in Fall River, Massachusetts says. “If they get bumped during transport, the packaging can get perforated. I've had students bring some instruments to a rotation and the blue wrap has been torn. So, it's always best to use  clean hands and maybe a transport container in order to get those to the end location, and not get them compromised in the process.”

When offices are bustling, that’s when little things can fall through the cracks. One such detail that can compromise the practice’s infection control efforts is falling behind on instrument sterilization.

“The biggest risk is if instrument reprocessing gets behind and then you're running multiple loads, trying to move those sterile items in and out of there as quickly as possible,” Moore observes. “Some instrument processing areas are really small, and that just increases the risk that something would be likely to happen.”

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Let them dry

Just because instruments have completed their machine sterilization cycle doesn’t mean that they are ready to go. Proper protocol requires that they be completely dry before being removed, or even handled.

“This is a problem across health care,” Spitzer says. “It’s not even just in dentistry. People are in a hurry and they don’t, maybe, have enough of a particular item. Let’s say it’s the dental handpiece. They are expensive and they only have a certain number of them. And now this particular load is just finished in the sterilizer, so they know that the sterilization heat and steam parts of the process are concluded and they opened the door. It’s just too easy to pull out all these items that are hot and wet. That allows microorganisms to easily penetrate the pouch from our hands, from the surfaces that you might lay the pouches on. We look at it and we’d see that the pouch is intact and there are no holes, and we think, ‘Oh, it’s safe.’ But it’s not, it’s really porous. So if it’s still wet and hot, it does allow all sorts of very tiny contamination going in and out of that pouch.”

The make and model of one’s sterilizer will dictate when instruments can be removed. As always, refer to the manufacturer’s instructions for use for correct guidance.

“The newer sterilizers have specific dry cycles, dry times,” Spitzer notes. “They may have alarms or signals or a little bell or something is built-in. The dry cycle on the newer models is a little bit more specific. On an older model, it might be more at the discretion of the user to understand that they do have to allow this period of time to dry and cool.”

Resist punctures

Instruments may seem safely wrapped in peel pouches, but that doesn’t mean that they should be handled any less gingerly. If damage does occur to those pouches, instruments are at risk of becoming contaminated.

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“Most dental instruments are sharp or pointed and, frankly, it’s a miracle that our pouches can take as much as they do,” Spitzer says. “The reality is, you’ve got a bunch of burrs, sharp scalers, you’ve got a curved Shepherd’s Hook Explorer. I mean, everything is sharp. And, again, this happens more readily when the pouch is a little bit damp and everything is hot. So that’s another good reason for waiting for items to dry and cool. It reduces the risk of puncturing or punching through. But as soon as there is a visible hole in the package, that should be a signal to the user that the bag, pouch, and contents need to be opened, rewashed and re-rinsed, re-dried, repackaged and reprocessed. That’s what reprocessing means is to put everything back to the process again because now it’s contaminated. You don’t use them.”

Manage items

In the dental practice, quarters can be tight. But even when that is the case, proper handling of instruments is necessary, but, regrettably, easy to overlook.

“Especially in a dental office, space is at a premium; there’s just never enough space, even for the basic steps of processing. There’s just never enough storage space,” Spitzer observes. “A lot of supplies and new things come in and you’re trying to keep the new fresh supplies in a clean place. You want to try to keep all the dirty separate from the clean. So people, in their minds, they’re thinking, ‘Well, I’m going to put these fresh supplies over here on this clean side where I’ve also got my sterile packaged items.’

"But that can be a big mistake because our supplies that are coming in might be clean, but they are oftentimes in boxes in which the outside of the box is very contaminated from shipping," Spitzer continues. "So you just do not want to have even clean supplies stored in the same drawers or cabinets with the sterile items. Keep the sterile items in their packages and keep them separated from all your other supplies. At least use separate drawers or shelves. Try to keep the dirty-to-clean concept in mind, because you really do want to make sure that your traffic flow does not create more contamination in the area where you’d store the sterile items.”

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The best way to manage that space, Spitzer says, is for everyone to get together and discuss safe handling procedures.

“A really good way to approach it is to have all of the people who are actually handling both the dirty and sterile items to have their own little meeting, or get-together in the area where they’re actually working, and do some workflow,” she recommends. “A couple of other people can watch them and comment to each other, but actually try the workflow to see where the problems might be. The most important thing is that the workflow doesn’t add to the contamination so that they’re not putting themselves in a situation where they’ll be re-contaminating those sterile items simply because of the way they have their workflows set up.

“Even if space is tight, there’s almost always a way to make it work effectively,” she continues. “And, frankly, at a certain point, an office may just need to invest in more efficient and effective storage. Yes, you can do a lot without spending money, but there will be a certain point that the office simply has to invest in better storage, new cabinets, maybe covers over shelves. There’s just as a point where it’s worth investing in better storage. It’s no different than bringing in your California closet.”

Let patients see

There is value in letting patients see, exactly, how instruments are handled. There may not be a clear, practical value in it, but there is something to be said when patients know that their safety is valued.

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“I’m a big fan of the PR value of doing the right thing,” Spitzer says. “So your office is investing in infection prevention. You’re training people, you’ve got better equipment, you’ve upgraded this thing, you do that thing. Don’t take for granted that people know and understand that you are doing the right thing. You want to make sure that your patients know about all the good things you’re doing -wash your hands in front of them; open your sterile packages in front of them. I think you want to moderate some of that, sometimes based on patient fear. You sometimes would prefer maybe to open the anesthetic syringe behind the patient. Maybe not in front of them, but there’s plenty of opportunity there for the dental staff to make sure that the patient visibly sees all the good things that they’re doing.”

The fact that the practice knows best procedures for instrument safety doesn’t mean that patients will automatically know. Letting them see how instruments are handled can send a reassuring message.

“It shouldn’t be automatically assuming, ‘Oh, the patients know our office is safe,’” Spitzer says. “You’re putting a lot of effort into infection prevention. Make sure that people see it and that they know it. There is a lot of power in that. That’s the kind of thing that people talk to each other about. They’ll tell their friend or relative, ‘Hey, you should go to my dentist. They’re really nice and I see all this stuff they’re doing. They sterilize this thing, they wash that thing. They’re always washing their hands in front of me. I know they’re really clean and they’re really safe.’ So, they may have a limited understanding of the science or the specific details, but I think that this PR value is really important for offices. It’s very powerful and you’re already doing it, so just do some of it in front of them.”

Reprocessing instruments goes beyond simply loading the sterilizer and pressing ‘Start’. How those instruments are handled – and what patients see – is key to maintaining their safety.