RE: Sterilization of Office Instruments (Robert
Gaynor, DPM)
From: Multiple Respondents
In response to Dr. Gaynor’s comments, .yes I
would recommend that you autoclave your
instruments with each routine foot care patient.
If you see 30 to 40 patients in one day, you
will need close to 20 complete nail packs. Have
your staff sterilize them prior to or during
lunch. That is what we do here and I can assure
you that I do not need to hire another person to
do that. It only takes about 10 to 15 minutes to
do.
Bryant A Tarr, DPM, Sudbury, MA,
brytarr@aol.com
Regarding the routine sterilization of
instruments used for routine palliative care in
the absence of exposure to blood or other bodily
fluids it would seem that the logical extension
of this “standard” would be full masking and
gowning and performing all palliative procedures
in a sterile environment as is done for invasive
surgical procedures. Therefore anyone NOT
performing all procedures in less than a full
sterile, aseptic environment would be in
violation of this standard and open to charges
of at least misconduct if not malpractice. This
seems to be a ludicrous situation and standard.
Established research has shown that 'surgically
clean' is, for most intents and routine
purposes, essentially equivalent to 'surgically
sterile'. It had been my experience and
professional exposure over 20+ years [yes, this
includes the time before gloves] that the
standard of care for palliative care which
involves
debridement, paring, and other manipulations of
inherently contaminated tissues was maintaining
a 'surgically clean' environment,
not 'surgically sterile'.
Has this in fact changed? When I resume daily
professional activities outside of my residency
should I plan on maintaining strict sterility in
all exam and treatment rooms and in all
procedures? Is this what is being done by the
majority of DPM's currently in practice?
H. David Gottlieb, DPM, Baltimore, MD,
hdavidgottliebdpm@gmail.com
I have been sterilizing all of my instruments
for many years. I agree
that the difficulty is the amount of time
involved. However if I went to a podiatrist,
dentist, or any physician who pulled instruments
out of a cold sterilization tray and approached
me with them, I would probably stop them before
they got the opportunity to use theses
instruments, and if I wasn't quick enough to
stop them I would not go back again. I think
people who are using cold sterilization are
losing patients and not realizing it. The loss
of patients pays for the time sterilizing the
instruments. Of course the reason we do it is
not for "practice management."
Kenneth Meisler DPM, Manhattan, NY,
Kenmeisler@aol.com
Dr. Gaynor is correct in that we live in a world
with diminishing reimbursement and time is
money. It costs money to use sterilizer bags and
one has to have many sets of instruments on hand
in order to carry out a 45 minute autoclave on
all of the instruments. The problem is that in
the real world there are dangerous diseases that
are blood borne. It does not take very much
blood to heaven forbid spread such diseases as
hepatitis A, B or C or even HIV and a drop of
blood on a nail cutter may be enough to spread
certain viruses to an open wound on another
persons nails. From time to time we all see
bleeding when we debride nails and many experts
argue that even if we don't see bleeding there
might be enough of an opening in the skin to
transfer bacteria and dangerous viruses.
Another factor is that if one is seeing 40
patients in a session and using the same dish of
chemicals to disinfect an instrument there is no
way that the chemical can come in contact for
enough time to kill all of the microorganisms
before transferring them to another patient.
As for the impact on ones office staff, my
experience of it is that it is minimal. In each
operatory we have an ultrasonic cleaner. The
ones made for jewelry stores are sufficient,
fairly inexpensive, quite professional-looking,
and far less expense than the ones marketed to
doctors. After each treatment, I place the
instruments used in the ultrasonic machine,
press the button, and go to the next patient. A
few minutes later my office assistant removes
the instruments, places them in a plastic
sterilizer bag and places it in the autoclave.
At the end of the day, she presses the button on
the autoclave and all of the instruments are
sterilized. It’s that simple and I sleep nights,
knowing that I did not cause any patient harm.
Elliot Udell, DPM, Hicksville, NY,
Elliotu@aol.com
Since Dr. Gaynor and I both practice in the
relatively same area, I
Can tell you what I do. I have about 20-25 sets
of instruments and they
Get steam autoclaved as they are used. South
Florida is such a hot bed of
Legal actions, I can not think of taking the
risk of treating a single
Patient with any instrument that was not fully
processed.
Maybe the deposition in the future might go like
this:
Q1- Doctor, can you show me the log of your cold
sterilization process?
Q2- Doctor, How often is the fluid in your cold
sterilization tank sent
For testing?
Q3- Doctor, Do you have a timer on each tray and
do you have the log
present today?
Q4- Doctor, Even if the instrument is sterile
from your cold process,
how is the "dead" human waste on the instruments
removed? Or is the next
patient inoculated with the previous persons
waste?
Q5 Doctor, do you have a autoclave and
ultrasound cleaning system
Within your practice?
You can see that this line of questioning can
never look good.....
Bret Ribotsky, DPM, Boca Raton, FL
In fact I do use autoclaved instruments
exclusively so as to avoid criticism. But I
will state again that there is no scientific
reason I know that prohibits clean, disinfected
instruments in the clinical scenarios I
originally described.
Dwight L. Bates, DPM, Dallas, TX,
dlbates04@yahoo.com
