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Instrument
Processing in the High Performance Dental Practice
As practices increase in their productive capacity, it
is common to see problems develop in the sterilization
and instrument processing area. Many practices notice
an increase in staff discord as this growth occurs. Insinuations
that one staff member is not pulling his or her weight,
and a belief that the practice does not have enough instruments
are common symptoms of this problem.
These stresses are indications of poor organization in
the sterilization area. Symptoms include grumbling between
staff members about sterilization responsibilities and
a backlog of instruments to be processed. If your practice
seems to have some of the recurrent symptoms of an inadequate
instrument processing system, perhaps it is time to evaluate
your process.
Symptoms of Instrument Processing Failures
• Need to purchase additional
hand instruments in the absence of substantial
practice growth.
• The need for full or part-time sterilization
staff in any practice.
• Inter-staff discord regarding sterilization
duties.
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In a slow practice, time is available for staff members
to process instruments inefficiently during gaps in a
loosely scheduled day, during cancellations and before
and after the doctor is at the practice. When doctors
improve their office scheduling, one result is staff complaints
regarding sterilization.
Unfortunately, in order to remedy this situation, we find
that most doctors' response is an attempt simply to speed
up their existing system rather than improving the system
itself. This is analogous to trying to motorize a slide
rule, rather than adopting computerization.
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(fig.1) - The rate limiting
step determines the flow rate of any process.
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Increases in speed alone are a recipe for failure because
of the principal of rate limiting steps (fig.1), which
states that an entire process will move no faster than
its slowest step. Efforts to speed up the process will
fail unless the entire process is accelerated in a balanced
manner. Examples of failure abound. Many doctors have
attempted to speed up the process by purchasing a small
capacity, high-speed sterilizer. Contrary to popular belief,
this will not speed up overall instrument processing.
Having emergency need for such a unit only points out
overall system weakness and lack of balance in the sterilization
sequence. The only way that low capacity units, such as
this, increase overall efficiency is through the use of
full-time sterilization staff, a concept that had many
proponents five or so years ago, but which does not and
will not make clinical or economic sense.
Another proposed remedy for sterilization bottlenecks
is the all-in-one stericenter, with its complicated -
have to go to school to figure it out - system. Sterilization
is best when the system is easy. Speed, simplicity and
reliability are the keys to successful sterilization.
You do not need to spend twenty thousand dollars in order
to obtain optimized sterilization!
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(fig.2) A whole office
cassette system markedly increases office performance.
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The first step in successful sterilization is simplification
of the instrument deployment system. For this, if you
have not already done so, it is strongly recommended that
you convert completely to a cassette system. (see fig.2)
Success in conversion to cassettes hinges upon two essential
elements. First, the establishment of a small number of
common setups - for example, operative (including crown
and bridge), endodontics, oral surgery, examination and
hygiene. Do not maintain a myriad of setups! Schemes that
were devised to simplify tray setup called for a broad
array of different tray types, each with a limited number
of instruments. These compact instrument arrays were planned
as a way to make individual tray setup less time consuming.
With cassettes, you are freed from constantly organizing
instruments; therefore having a greater number of instruments
available for a given procedure is simply a convenience.
This allows a single set up to handle a wide range of
services. It will decrease set up time and will allow
greater flexibility in cassette use (for example - our
office can easily complete a post and core using only
our endodontic cassette; an exam cassette can accommodate
a simple filling or an orthodontic ligature change and
an operative cassette will accommodate any restoration).
When instruments are processed in cassettes, you eliminate
handling throughout the contaminated portion of the processing
cycle. The success of this strategy depends upon two preconditions.
One, cements and resin must be removed at chairside. This
is necessary in any event. No instrument processing technology
will remove today's cements when they are allowed to set
on your equipment. Two, instruments should not be allowed
to fully dry prior to processing. A processing pre-soak
as instruments wait for processing delays is imperative.
| Now
that you have streamlined your transport system,
the sterilization sequence itself becomes simpler
and far more productive. |
Here is a list of the steps in an efficient
sterilization system:
1. Presoak instruments in
order to loosen and dissolve organic debris;
2. Power wash instruments to remove accretions;
3. Bag or wrap cassettes if desired;
4. Autoclave or dry heat as appropriate
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It's that simple. Let's detail each of these
steps:
Presoaking is an important, but often overlooked, element
in the sterilization sequence. Presoaking markedly increases
the effectiveness of subsequent steps. Presoaking will
never be lauded by our dental equipment and supply dealers
as it costs pennies and requires no expensive instrumentation.
Simply dedicate an appropriately sized sink or basin
for soaking and place your cassettes in a diluted enzymatic
or caustic solution. As the successive portions of the
sterilization process become ready for action, you are
able to transfer cassettes out of the rinse and into
the instrument wash. Should you desire to treat certain
instruments, for example orthodontic pliers or handpiece
burs (fig. 3), with dry heat, these can be segregated
early in the sequence. A ėmilk bath' pretreatment is
an alternative pretreatment option that may be desirable
for the carbide tips of such components.
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(fig.3) Bur cassettes
allow carbide instruments to be processed by
dry heat if desired.
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Instrument washing is the next step in the processing
sequence. Automating this with a dishwasher (see fig.
4) is a simple, logical method. Contrary to popular
belief, most offices do not need a high cost, high-speed
unit. In order to understand this, you may have to reach
back to chemistry class and the concept of rate limiting
steps. Basically, a process will run no faster than
its slowest step will permit. Don't buy an expensive
high-speed washer until you have decided on an autoclave
- both with regard to cycle time and capacity.
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(fig.4) - Dental use
of instrument washers has grown significantly
in recent years.
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With instruments successfully washed, moving on to actual
sterilization is a simple task. However, there are many
misconceptions. First, size matters. You've got to be
able to fit multiple full-sized cassettes in your autoclave
or you are wasting your time. Too many offices have
full-time sterilization staff simply because they are
too cheap to throw out a working, but inadequate, autoclave.
Big is better because a unit that handles seven or more
cassettes slowly is much faster than a high-speed processor
doing one cassette at a time. Batch processing is also
much more labor efficient. If desired, cassettes dry
upon removal from the washer are now wrapped or bagged
for autoclaving. This step is not without some controversy.
The issue concerns the need for wrapping in private
practice. Wrapping instruments does decrease sterilization
efficiency; however, the wrapped cassette is then protected
from potential airborne contaminates post processing.
However, when this is compared to the typical tray setup
or drawer storage, it is common to find offices that
set out instruments by hand on open trays once autoclaved.
As many doctors argue, even storage of unwrapped cassettes
in a clean storage cabinet is a significant improvement
over the protection offered with tray setup*.
Once you have reorganized your system in order to permit
efficient workflow, you will find that the sterilization
constraints that you have been experiencing simply fade
away. This will allow for significant practice growth.
None-the-less, after significant growth has occurred,
you may find that you wish to further speed up the system.
The way to do this is simply by reducing the time for
each step. Fortunately, this has become possible recently
due to the advent of new high speed, high capacity autoclaves.
At the beginning of this article, we briefly discussed
rate limiting steps. Historically in sterilization,
the rate limiting step has been actual disinfection.
This is because spore kills are time dependent. While
this remains true today, that time has been markedly
reduced by the chamber preheat capabilities of newer
autoclaves. The first significant reduction in autoclave
processing time came with the introduction of the SciCan
Statim, by using a small chamber volume - a single cassette.
Recently, units such as the Tuttnauer 2540 EHS or the
Barnstead PV Dry have been introduced, which both increase
speed and have adequate chamber volume. Each of these
autoclaves has the combined advantages of room for multiple
cassettes and rapid pre-heating, similar to, but not
as quick as the popular Statim units. The large capacity
of these full sized autoclaves more than compensates
for the modest reduction in cycle time. It should be
noted that if you think that you may be a candidate
for a high-speed autoclave, you should make sure that
you choose a dishwasher with a comparable short wash
cycle in order to balance your workflow.
| Process Cycle Times (fig. 5) |
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| "slow conventional autoclaving
is often faster than the "fast"
process method." |
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With process "A", the first instruments clear
the sequence in 2 hours. Subsequently, instruments
clear sterilization on an hourly basis.
Process "B" will clear the first series of instruments
in two hours, but subsequent allotments are still
on a 1 hour process time.
Only process "C" will reduce actual
in-practice workflow; however, if the autoclave
capacity is reduced to 1/10th the original capacity,
net production time will actually increase.
(fig. 5) |
Sterilization does not have to be difficult. It is successfully
organized through a diligent work simplification process.
Reliability and labor savings should be your primary
goals. With this successfully accomplished, speed and
ease of use will naturally follow.
D/E
*Our company and this author neither recommend nor
endorse a particular sequence of disinfection or sterilization.
This article is intended to simply illustrate choices
to be made in the sterilization sequence.
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