Is an autoclave necessary?

[DYK343]

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As a total toenail replacement surgeon, I keep my clinic running smoothly by requiring all patients to have both socks and rotten bedroom loafers off before I enter the room. If I open the door and they have their socks still on then I’ll immediately make a U turn at the door and let them know they can have a few minutes to get situated with their socks off. I will then go see another patient entirely.

Why you gotta bring up the loafers?
Its a saturday

 

[Creflo]

Huh? In this case the sterilization is to prevent the spread of blood borne pathogens (from previous patient). Not to protect nail number one from nail number two.

So staph aureus in blood is different than staph aureus on skin?

 

[DYK343]

So staph aureus in blood is different than staph aureus on skin?

Passing pathogens person to person (Hep C, HIV, MRSA, etc) is not the same as using the nippers to cut all the nails.

Im really confused about your argument.

 

[dtrack22]

So staph aureus in blood is different than staph aureus on skin?

Well yeah. You can have staph colonization on your intact skin without any sort of pathologic response. Not so much once you’re bacteremic. Is this a serious question?

 

[Pronation]

Gentlemen are we not most concerned though about Trichophyton rubrum?!?!?!?!11

 

[MicroPod]

For concierge podiatry service, we should offer to dip patients feet into the communal green liquid and be autoclaving their socks and loafers as well. This will help retain patients from the anti-moustache hospital podiatrists that hurt our profession.

 

[Creflo]

Passing pathogens person to person (Hep C, HIV, MRSA, etc) is not the same as using the nippers to cut all the nails.

Im really confused about your argument.

Just sayin we use sterile nippers, but as soon as you cut through some of the nastiest material on the human body, you aren't sterile.

 

[Pronation]

Just sayin we use sterile nippers, but as soon as you cut through some of the nastiest material on the human body, you aren't sterile.

 

[Jummy Biffett]

We're (hopefully) not breaking the skin barrier with these 'non-sterile' nail nippers on nails 2-10 so the argument of maintaining surgical sterility doesn't make a ton of sense in my book. Maybe there's a hypothetical argument when using the same nippers on a fungal hallux nail and a healthy 2nd toenail, but let's be honest, that nail has already been exposed to T. rubrum anyways. Nail jail gang for life!

 

[Hybrocure]

Should we be trimming the nondystrophic nails first to avoid cross contamination with the mycotic nails, instead of going straight down the line?

God, I remember I used to ponder things like morality, life after death, the meaning of life. Now I think about this. Sometimes I hate what podiatry has done to me.

I usually go in order for easiest to trim and save the big boys for last, it helps manage time better. So it does sort of work out more hygienic I suppose

 

[Pronation]

I usually go in order for easiest to trim and save the big boys for last, it helps manage time better. So it does sort of work out more hygienic I suppose

Powerful critical thinking skills

 

[Hybrocure]

Powerful critical thinking skills

Thank you. Maybe one day these skills will help me qualify to do TTR’s at my local hospital.

 

[deleted285117]

Be sure you soften them nails with 3-Wea first 😜

 

[air bud]

Thank you. Maybe one day these skills will help me qualify to do TTR’s at my local hospital.

Yeah, that's definitely a hospital thing no way in ASC wants to eat the hardware costs associated with that. Way too many components it just doesn't reimburse well for them.

 

[Sybly]

I have seen a large spectrum of disinfection methods in my short podiatry life. From an office that reused scalpels if no blood was drawn to an office that used an autoclave for every single use of nail nippers.

Is cold sterilization enough for nail nippers or do I need to buy 40 for daily use?

I know podiatrist doesn’t even sterilize instruments for c and c ??!!?!

 

[Sybly]

Is it theoretically possible to do OK with nursing homes, I suppose.

Unfortunately this assumes a lot of things.

You have no office overhead

You have no surgical malpractice

You bring no staff to assist

You do not use disposable instruments

You have facilities with helpful staff to assist with patient care and paperwork required for billing

Other things to consider

To have enough facilities to make a career of it you will often need to drive far.

Then there is often politics to keep facilities as those in charge sometimes think you have a goldmine and want something in return.

You also risk eventually getting an audit that causes disruption of cash flow or results in paybacks. If this happens it will be extra stressful with almost all of your income coming from Medicare. You risk much worse and will likely eventually get caught if coding for nail avulsions and patients you never saw.

Then as mention the toll it can take on one's body.

If one picked up a couple facilities when they started out and kept them because they are very close and well run, then going a day or two a month might be productive enough days to justify.

Some can practice lobster podiatry and make it work. Good for them, if it is better than their other options. It is still a real bad sign for our profession that we are still doing this.

The best use of nursing homes is temporary lobster podiatry as we have few options for moonlighting is a side hustle while saving to open a practice or during the very early years of opening a practice if necessary.

A lot podiatrist overbill there. A lot callus and E and M - some net over 200 k

 

[Homo sapien]

Sterile Solutions. They are UK based, but have a U.S. distributor. DM me if you want me to look for their contact.

Do you still use them as a distributor

 

[diabeticfootdr]

Do you still use them as a distributor

We still use the instruments. The distributor is US-based.

 

[Sybly]

I have seen a large spectrum of disinfection methods in my short podiatry life. From an office that reused scalpels if no blood was drawn to an office that used an autoclave for every single use of nail nippers.

Is cold sterilization enough for nail nippers or do I need to buy 40 for daily use?

Cold sterile just fine

 

[heybrother]

Cold sterilization isn't getting any love from AI (output below)
----

Using "cold sterilization" (soaking metal instruments in liquid chemical buckets) does not meet the regulatory expectations of the CDC, OSHA, or State Medical Boards if the manufacturer’s required soak times are not strictly met, or if the chemical is only capable of "high-level disinfection" rather than full sterilization. [1, 2, 3]
Federal and state organizations have specific, strict expectations concerning office sterility and infection control: [1, 2]

1. The Government Organizations
Several agencies put out and enforce expectations regarding in-office sterility for podiatrists:

• • Centers for Disease Control and Prevention (CDC): The CDC provides the foundational scientific guidelines for infection prevention in outpatient podiatry settings. [1]
  • Food and Drug Administration (FDA): The FDA regulates the liquid chemical sterilants and sterilizing equipment used by practitioners. [1]
  • Occupational Safety and Health (OSHA): OSHA enforces worker safety, ensuring that staff members are not exposed to toxic chemical vapors without proper PPE and that offices have strictly documented infection control plans. [1]
  • State Medical Boards / Health Departments: Depending on your location (such as the Texas Department of Licensing and Regulation in your vicinity), state health boards adopt these federal guidelines into legally binding state regulations. [1, 2]

2. Regulatory Stance on "Cold Sterilization"

• • The Spaulding Classification: Nail nippers and curettes are classified as semi-critical devices because they routinely contact non-intact skin. The CDC requires that these instruments undergo heat sterilization (such as an autoclave) if they are heat-resistant. [1]
  • When chemicals are allowed: Cold chemical sterilization is only considered acceptable by the CDC if an instrument is completely heat-sensitive and no alternative exists. Even then, to achieve true chemical sterilization, instruments often must soak for 10 hours or more in FDA-approved liquid chemical germicides. Shorter soaks are considered "high-level disinfection" and do not achieve true sterility. [1, 2, 3, 4, 5]
  • The Issue of Timing: Relying on a quick "bucket dunk" between patients falls dangerously short of both chemical sterilant requirements and heat sterilization expectations.

For further details, you can read the official CDC Guide to Infection Prevention for Outpatient Podiatry Settings. [1]

If you are concerned about a specific podiatry office's practices, tell me:

• What state is the clinic located in?
• Do you know if they also offer surgical or wound-care procedures?

I can help you find your state's specific medical board regulations and reporting procedures.

These are from the Pennsylvania Department of Health linked above.
-------------
Infection control breaches in podiatric care related to improper instrument sterilization and crosscontamination of clean and dirty instruments and surfaces have been associated with outbreaks ofbacterial infection and blood-borne pathogen transmission including hepatitis B virus outbreaks.1-3 Someof these outbreaks have occurred in long-term care settings.1-3The Pennsylvania Department of Health (DOH) and Philadelphia Department of Public Health (PDPH)have observed infection control practices by podiatrists that are not aligned with CDC guidelines inlocations across the state, both within the clinic setting and while podiatrists provide services within longterm care facilities (LTCFs). Although not representing a systematic review of practices, observedpractices that did not follow the Centers for Disease Control and Prevention (CDC) guidelines included,but were not limited to, poor or absent hand hygiene, failure to clean and disinfect or sterilize semi-criticalinstruments between patients, cross-contamination of instruments and surfaces, and utilizing potentiallyineffective methods of cleaning or disinfection, for both instruments and environmental surfaces.
-------------
Cleaning and Disinfection or Sterilization of Reusable Instruments• Cuticle and nail nippers, curettes, forceps, dissecting scissors, nail cutting instruments, andelectronic nail files are all examples of semi-critical instruments used for podiatric care. Theseinstruments have the potential to contact mucous membranes or non-intact skin and are semicritical instruments according to CDC guidance following the Spaulding Classification. Allreusable semi-critical instruments should undergo a sterilization process using steam sterilizationif they are heat resistant (i.e., metal instruments) or at a minimum, high-level disinfection betweenpatients.o Reprocessing of semi-critical instruments is a multi-step process that includes cleaning,inspection, disinfection or sterilization, and proper storage. Following manufacturers’instructions and all steps outlined within the CDC guidance are critical to theimplementation of safe patient care.o If the manufacturer does not provide instructions for reprocessing instruments, theyshould be considered single-use items, used only once, and then discarded.• Medical instruments that have contact with sterile body tissue or fluids are considered critical instruments and must be cleaned and sterilized before use. These include surgical instruments,scalpel blade handles, and biopsy forceps. If these items are heat resistant, the recommendedsterilization process is steam sterilization.• If cleaning does not begin immediately after the provision of care, pre-cleaning should beperformed as soon as practical after use (e.g., at the point of use) to prevent soiled materials frombecoming dried onto instruments.• Refer to the CDC’s Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 fordetailed information about sterilization and disinfection (available at:Infection Control for Healthcare Providers guidelines/disinfection/index.html).

 

[DogSnoot]

Cold sterilization isn't getting any love from AI (output below)
----

Using "cold sterilization" (soaking metal instruments in liquid chemical buckets) does not meet the regulatory expectations of the CDC, OSHA, or State Medical Boards if the manufacturer’s required soak times are not strictly met, or if the chemical is only capable of "high-level disinfection" rather than full sterilization. [1, 2, 3]
Federal and state organizations have specific, strict expectations concerning office sterility and infection control: [1, 2]

1. The Government Organizations
Several agencies put out and enforce expectations regarding in-office sterility for podiatrists:

• • Centers for Disease Control and Prevention (CDC): The CDC provides the foundational scientific guidelines for infection prevention in outpatient podiatry settings. [1]
  • Food and Drug Administration (FDA): The FDA regulates the liquid chemical sterilants and sterilizing equipment used by practitioners. [1]
  • Occupational Safety and Health (OSHA): OSHA enforces worker safety, ensuring that staff members are not exposed to toxic chemical vapors without proper PPE and that offices have strictly documented infection control plans. [1]
  • State Medical Boards / Health Departments: Depending on your location (such as the Texas Department of Licensing and Regulation in your vicinity), state health boards adopt these federal guidelines into legally binding state regulations. [1, 2]

2. Regulatory Stance on "Cold Sterilization"

• • The Spaulding Classification: Nail nippers and curettes are classified as semi-critical devices because they routinely contact non-intact skin. The CDC requires that these instruments undergo heat sterilization (such as an autoclave) if they are heat-resistant. [1]
  • When chemicals are allowed: Cold chemical sterilization is only considered acceptable by the CDC if an instrument is completely heat-sensitive and no alternative exists. Even then, to achieve true chemical sterilization, instruments often must soak for 10 hours or more in FDA-approved liquid chemical germicides. Shorter soaks are considered "high-level disinfection" and do not achieve true sterility. [1, 2, 3, 4, 5]
  • The Issue of Timing: Relying on a quick "bucket dunk" between patients falls dangerously short of both chemical sterilant requirements and heat sterilization expectations.

For further details, you can read the official CDC Guide to Infection Prevention for Outpatient Podiatry Settings. [1]

If you are concerned about a specific podiatry office's practices, tell me:

• What state is the clinic located in?
• Do you know if they also offer surgical or wound-care procedures?

I can help you find your state's specific medical board regulations and reporting procedures.

These are from the Pennsylvania Department of Health linked above.
-------------
Infection control breaches in podiatric care related to improper instrument sterilization and crosscontamination of clean and dirty instruments and surfaces have been associated with outbreaks ofbacterial infection and blood-borne pathogen transmission including hepatitis B virus outbreaks.1-3 Someof these outbreaks have occurred in long-term care settings.1-3The Pennsylvania Department of Health (DOH) and Philadelphia Department of Public Health (PDPH)have observed infection control practices by podiatrists that are not aligned with CDC guidelines inlocations across the state, both within the clinic setting and while podiatrists provide services within longterm care facilities (LTCFs). Although not representing a systematic review of practices, observedpractices that did not follow the Centers for Disease Control and Prevention (CDC) guidelines included,but were not limited to, poor or absent hand hygiene, failure to clean and disinfect or sterilize semi-criticalinstruments between patients, cross-contamination of instruments and surfaces, and utilizing potentiallyineffective methods of cleaning or disinfection, for both instruments and environmental surfaces.
-------------
Cleaning and Disinfection or Sterilization of Reusable Instruments• Cuticle and nail nippers, curettes, forceps, dissecting scissors, nail cutting instruments, andelectronic nail files are all examples of semi-critical instruments used for podiatric care. Theseinstruments have the potential to contact mucous membranes or non-intact skin and are semicritical instruments according to CDC guidance following the Spaulding Classification. Allreusable semi-critical instruments should undergo a sterilization process using steam sterilizationif they are heat resistant (i.e., metal instruments) or at a minimum, high-level disinfection betweenpatients.o Reprocessing of semi-critical instruments is a multi-step process that includes cleaning,inspection, disinfection or sterilization, and proper storage. Following manufacturers’instructions and all steps outlined within the CDC guidance are critical to theimplementation of safe patient care.o If the manufacturer does not provide instructions for reprocessing instruments, theyshould be considered single-use items, used only once, and then discarded.• Medical instruments that have contact with sterile body tissue or fluids are considered critical instruments and must be cleaned and sterilized before use. These include surgical instruments,scalpel blade handles, and biopsy forceps. If these items are heat resistant, the recommendedsterilization process is steam sterilization.• If cleaning does not begin immediately after the provision of care, pre-cleaning should beperformed as soon as practical after use (e.g., at the point of use) to prevent soiled materials frombecoming dried onto instruments.• Refer to the CDC’s Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 fordetailed information about sterilization and disinfection (available at:Infection Control for Healthcare Providers guidelines/disinfection/index.html).

Cold sterilization is crazy. I agree with the AI bots.

 

[Steveington]

If something is sterilized, you should feel confident with putting it in your mouth. Something that's been autoclaved? Sure. Something that's in cold sterilization? No way!

 

[dtrack22]

you should feel confident with putting it in your mouth

I put toes in my mouth so you’re talking to the wrong guy…

 

[Steveington]

I put toes in my mouth so you’re talking to the wrong guy…

I'm not nearly that flexible

 

[dtrack22]

I'm not nearly that flexible

They aren’t mine, weirdo.

 

[eyeeye_captain]

I put toes in my mouth so you’re talking to the wrong guy…

I think you’ll get a little more antiseptic mileage out of chlorhexidine or betadine

 

[dtrack22]

I think you’ll get a little more antiseptic mileage out of chlorhexidine or betadine

I don’t tell you how to do your job, buddy

 

[Adam Smasher]

If something is sterilized, you should feel confident with putting it in your mouth. Something that's been autoclaved? Sure. Something that's in cold sterilization? No way!

In my office break room, my staff and I have communal silverware that we share and hand wash and don't have any qualms about putting in our mouths.

So yeah my gluteraldehyde works just fine. We've had zero nail-trim associated skin and soft tissue infections (NASSTI) btw

 

[heybrother]

In my office break room, my staff and I have communal silverware that we share and hand wash and don't have any qualms about putting in our mouths.

So yeah my gluteraldehyde works just fine. We've had zero nail-trim associated skin and soft tissue infections (NASSTI) btw

As of late - the more I read the forum the more I feel like none of us are meeting goverment regulation.

I now bag and autoclave everything, but I haven't yet implemented spore testing. So I'm presumably not in compliance. I don't think a single person replied to my prior query about spore testing because no one is doing it.

I have 4 Midmark chairs, but none of them are ADA compliant. More frustrating still - had I been aware of the rule I could have simply bought 1 less chair and actually bought an ADA compliant chair. To purchase an ADA compliant chair I would now need to sacrifice a chair

 

[Adam Smasher]

Much of my practices are holdovers from my now retired partner. Theres a lot of inconsistency. I don't bother thinking about. I don't autoclave nail nippers, but I do spore test. I also have a sterile instrument pack for ingrown. But I don't skin prep the toe before removing the ingrown, which probably works against the purpose of sterility.

The state requires us to have a sign saying "x-rays in use beyond this point." But a few years ago I moved the xray closer to the entrance. Never bothered to move the sign.

 

[diabeticfootdr]

They aren’t mine, weirdo.

Hopefully not patients' either ...

 

[Mia McBhul]

Hopefully not patients' either ...

theres just too much competition in our field. we have to do whatever it takes to get an edge on our competition..

 

[heybrother]

16 Tex. Admin. Code § 130.57 - Sexual Misconduct

www.law.cornell.edu

I'll never forget prepping for the Texas Jurisprudence exam and thinking "damn, they really spell out sexual contact" these sex acts.