Patient Safety in Practice: Tawam Hospital Dental Services

Editor’s note: Tawam Hospital Dental Services—under the direction of Tawam Hospital, a Joint Commission International–accredited organization in the eastern region of the Emirate of Abu Dhabi—has created Infection Control Guidelines to instruct staff on best practices for eliminating or mitigating infections in the course of their everyday duties. The following excerpt is from Chapter 3: Infection Control in the Central Sterile Supply Department, and is presented her as direction for dental or other health care organizations seeking to better prepare frontline workers to prevent or reduce the risk of infection. JCI extends special thanks to Sumaya Al Harrasi, Section Head, Business Development, Tawam Hospital and Diane M. Chapman, Infection Control Member, for their assistance.

Chapter 3: Infection Control in the Central Sterile Supply Department
The Central Sterile Supply Department (CSSD) at Tawam Hospital is the main hub of the Tawam Hospital Dental Services. Here, sterilization and disinfection of all instruments are done in a sterile and efficient environment. This department plays a vital role in the daily functioning of the dental center. The infection control and sterilization steps performed here are of paramount importance in the management and prevention of infection control in the entire dental center.

Contaminated instruments go through several steps and cycles in order to complete disinfection and sterilization. The CSSD is designed to allow the distribution of instruments during each step to take place in a specific isolated area; for example, delivery of contaminated instruments is isolated from the area of packing and sterilization, and from the area of delivery of clean instruments.

All CSSD staff should wear the appropriate personal protective equipment (PPE) relevant to the different areas in which they are working.
                                         
Soiled Instruments
Multiple-use Items and Devices
Soiled multiple-use items and devices are brought to the soiled instruments room. The dental nurse places all trays/boxes into the containers as marked which are then ready for collection. Every hour throughout the day, porters will pick up and transfer the item/device containers by trolley to the CSSD in the New Dental Center (NDC) building.

Soiled items/devices are deposited in the soiled instrument trolleys ready for collection. Porters collect the soiled items/devices hourly and place them in a covered trolley and then transfer to the CSSD for processing. Items and devices are classified and sterilized as described in Table 1:

Table 1. Dental Instruments by Category and Sterilization Method

Source: Tawam Hospital Dental Services. Used with permission.

Single-use Items and Devices
Single-use items and devices are intended to be used on an individual patient during a single procedure and then disposed of. Items designed for a single use must NOT be reprocessed. Single-use packaging may be labeled as follows:
• Disposable (see Photo 1)
• For single use only (see Photo 2)
• A symbol indicating no second use is allowed (see Photo 3)

Photo 1. “Disposable” Label
 
Source: Tawam Hospital Dental Services. Used with permission.


Photo 2. “For Single Use Only” Label
 
Source: Tawam Hospital Dental Services. Used with permission.

Photo 3. “No Second Use” Label  

Source: Tawam Hospital Dental Services. Used with permission.

Sterilizers
Sterilizers vary by the types of indicators and the readings they provide regarding the mechanical or physical parameters of sterilization—time, temperature, and pressure. Steam sterilization is most widely used for wrapped and unwrapped critical and semicritical instruments that are not sensitive to moisture or heat. Tawam Dental Center uses a high-speed prevacuum sterilizer. Staff should do the following to operate the sterilizer properly:
• Follow the manufacturer’s instructions for proper use of the sterilizer
• Allow packages to dry in the sterilizers before removing them

Instrument Processing Area
In CSSD all processing areas are separate. The central area is divided into the following sections:
• Receiving area
• Cleaning and decontamination area
• Sterilization area
• Storage area

Receiving, Cleaning, and Decontamination Areas
The procedures for receiving, cleaning, and decontaminating are as follows:
• All reusable instruments are received in the decontamination room (see Photo 4).
• All instruments are placed in wire mesh baskets, trays are arranged in tray racks, and are placed in the washer/disinfector
  (see Photo 5) for automatic cleaning from blood, saliva, and debris.
• Manual cleaning is only done for burs and endodontic files, which are then placed in the ultrasonic cleaner, and handpieces
   (which cannot be immersed).
• Large/heavy instruments are separated from the lighter ones.

Photo 4. Decontamination Receiving Area

Source: Tawam Hospital Dental Services. Used with permission.

Photo 5. Washer/Disinfector
 
Source: Tawam Hospital Dental Services. Used with permission.

Preparation and Packaging
Preparation of clean, sterile instruments is done in an area separate from the decontamination area as follows:
• Cleaned instruments are inspected for dental material, visible soil, and rust and then assembled into sets or trays.
• Instruments are checked for breakage and damage.
• All hinged or articulated instruments are placed in an open position (for example, scissors, haemostatic forceps, extraction
  forceps, among others).
• Instruments are packed using a container or wrapping compatible with the method of sterilization (for example, heat-sealed
   peel pouches are sterilized by steam; tyvek pouches receive plasma sterilization). (see Photos 6 and 7)

Photo 6. Packaging Instruments 
 
Source: Tawam Hospital Dental Services. Used with permission.

Photo 7. Packaged Instruments
 
Source: Tawam Hospital Dental Services. Used with permission.

Sterilization Area
In the sterilization area, use the following process:
• Heat-tolerant dental instruments are sterilized by steam under pressure
• Items to be sterilized are arranged to permit free circulation of steam.
• Place the batch monitoring device on basket with instruments
• Packs should be allowed to dry inside the sterilizer.
• Packs should not be touched until they are cool and dry, as hot packs act as wicks, absorbing moisture and therefore 
  bacteria from hands.
• All items are placed in dust-covering plastic bags.
• Instruments are then distributed to the appropriate dispensing areas.
• Important: Flash sterilization is not practiced in the dental center.

Sterilization Monitoring
Use chemical and biological monitors according to the manufacturer’s instructions to validate the effectiveness of the sterilization procedures. Use the following steps to correctly monitor sterilization:
• Perform a daily leak test and warm up cycle. This verifies the ability of the sterilizer chamber to resist air leakage during the
  vacuum period.
• Perform a Bowie-Dick simulation test at the beginning of each day to monitor air removal and steam penetration.
• Do a batch monitoring system on each cycle to monitor the steam sterilization process.
• Perform a mechanical monitoring system to check sterilization parameters, including assessing the cycle time,
   temperature, and pressure.
• Monitor sterilizers twice a week and each implant load with biological indicators (see below).
• If one of the bars on the strip is either yellow or is between yellow and brown, the sterilization process is insufficient.
• If all bars on the strip have turned from yellow to black sterilization is successful.

Biological Indicators. Biological indicators are harmless bacterial spores in a vial with two separate sections. The spores are placed in the inner layer for safety and in the outer layer there is a liquid that is a suitable media for bacterial growth. The indicators test the sterilization process as follows:
• This vial is placed inside the autoclave and a 4-minute cycle is run at 134°C; a 20-minute cycle at 121°C is run for sensitive
   items.
• After the cycle ends, the vial is crushed to mix the spores with the medium. If the spores are present in the media and at
   incubator temperature, bacteria will grow.
• Incubation should last 3 hours at 60°C.
• The reader automatically detects the presence of spore-associated enzymes as follows:
   - The red light indicates the sterilization process failed.
   - The green light indicates the sterilization process was effective.

Recording Results. Each test is recorded in the Steam Sterilizer Indicator Record Book— a reference book showing the daily status of sterilizers in CSSD and the effectiveness of the sterilization process—which is kept in the CSSD.

Water Quality Monitoring
The water quality is tested every two weeks for bacteriology and chemical analysis to make sure that the water supply to the dental center is safe. The water supply is tested every two weeks for hardness, total dissolved salts (TDS), alkalinity (pH), iron content and conductivity. Preventive medicine personnel test the water once a month for waterborne microorganisms.

Storage Area in Clinics
Storage area should contain enclosed storage for sterile items and a separate area for disposable items. Clean supplies and instruments should not be stored under sinks or in other locations where they might become wet or compromised. Instruments are packaged using event-related sterility (no expiration date). This system recognizes that the product remains sterile indefinitely, unless an event causes it to become compromised (for example, a wet or torn package).

Packages containing sterile supplies should be inspected before use to make sure barrier wrap has not been compromised. If a package is compromised, the instruments should be recleaned, repackaged, and resterilized.