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

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. 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 QH Commitment

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

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 Don’ts 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 won’t 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 manufacturer’s 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. DoubleSink 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 manufacturer’s 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 manufacturer’s 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 manufacturer’s instructions Non-immersible cannulated items - the manufacturer’s 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 manufacturer’s 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.