There’s a chance that certain infection control protocol isn’t being followed in the dental practice. How can we ensure that we avoid common pitfalls in infection control protocol?
Mistakes happen. No one likes it, but they do. Unfortunately, infection control mistakes can be more serious than an innocent typo or a door ding. The consequences of an infection control mistake include personal injury, fines, or even damage to the practice’s reputation. Often, practices tend to make universal mistakes, and identifying those gaffes can help prevent them from recurring in other practices.
The hub of the practice’s infection control efforts is its sterilization area. Being such a central area also leads to opportunities for errors and inefficiencies.
“What’s wonderful is that the Centers for Disease Control (CDC) has given us great guidance in instrument reprocessing,” infection prevention speaker and consultant Karen Daw, “The OSHA Lady” advises. “Dental assistants – and sometimes dental hygienists – are the ones responsible for cleaning the instruments. They’re trained on it. But then we see that there are lapses in this area, and what concerns me the most is that this is an area where we have the potential to do the greatest amount of harm. Usually, when you hear about infection control breaches involving instruments, that’s what’s landing practices and major hospitals on the front page of the national news. So, it always interests me: Why is there such a breakdown? Some of the things that I observe, for example, are that we don’t know the 4 areas within sterilization: Receiving, cleaning, and decontamination; preparation and packaging; sterilization; and storage. And yet one of the things that I see is a really poor workflow in this space where people are kind of ping-ponging around, or we don’t have enough space to give our team members to be able to process instruments safely in a unidirectional flow. I remember my very first job in a dental practice: I was cleaning instruments in a closet – it was a former dark room, not nearly enough space to be able to do my job properly. A flow in that area is something that we could do better to set up our team for success and minimize potential injury and infection control breaches.”
The gravest infection control mistakes occur in the operatory in the presence of a patient. However, it’s easy to forget that some infection control chores have nothing, physically, to do with a patient, an instrument,or a location. There is a lot of routine paperwork required at the practice, and it’s easy to overlook.
“In the 22 years that I’ve been consulting, the number one issue is documentation,” Olivia Wann, JD, the founder of Modern Practice Solutions, says. “You can’t say, ‘Yes, we do that,’ We have to prove it.Safer device evaluations are not being conducted annually, and there’s no documentation if it is being done. Required training is not being provided on infection control and bloodborne pathogens and other Occupational Safety and Health Administration (OSHA) -required topics. Rosters are not in compliance with OSHA. Chemical inventories are either non-existent or not current. Medical records for the employees are either non-existent or not current.”
So, who is responsible for all that paperwork?
“It would be the employer, but that usually gets delegated,” Wann observes. “And that’s another thing to build on, is that the employer is responsible, but have they delegated these duties to certain individuals, such as the infection prevention coordinator? Unless someone has been delegated that role and provided with a job description – which is usually secondary to their main job function – are they prepared for that role? The delegation needs to be dependent on having an individual that not only has a skillset for it but enjoys the subject matter.”
Personal Protective Equipment (PPE)
The last line of defense in the National Institute of Occupational Safety and Health’s (NIOSH’s) Hierarchy of Controls is PPE. That is, onceeverything else has been done to mitigate infection risks; it’s up to PPE to protect staff and patients. As such, mistakes are easy to make.
“Something else that I see in this space is the lack of utility gloves and lack of appropriate personal protective equipment, chairside,” Daw says. “If we’re expecting spatter and spray, we’re going to wear eyewear and masks and gowns and gloves. And the eyewear and masks, obviously, are to protect our mucus membranes. And yet, when they’re cleaning instruments at a sink, for example, or transferring items in and out of an ultrasonic, there’s still potential for spatter and spray. And yet, the team’s not wearing the appropriate PPE. They’re not covering their eyes, nose, and mouth the way they would if they were chairside, anticipating the same hazard.
“And then utility gloves,” she continues. “Anybody who’s gone through any type of formal instrument processing education knows to use utility gloves. Many of our dental assistants were taught in dental assisting school to use them, and yet they go into private practice and sometimes it’s not available, or if it’s available, it looks like it’s brand new, fresh out of the package. No one’s ever bothered to use it. So, then we fail them in that regard.”
That PPE inconsistency, Daw says, is what leads to preventable accidents.
“They work in a practice where the culture is, ‘Ah, we’re rather dismissive. We don’t use utility gloves here’,” Daw says. “These are common, but it’s so obvious, too. We have guidance and standards available to us. We were educated on it. We sit through OSHA training every single year. And infection control training in many states is a mandatory requirement for license renewal. We are hearing this information, but we’re not applying it. The ‘why’ behind why we’re not applying it could be the culture in the practice, and we have a busy practice owner that can’t be everywhere all at one time.”
While the buck may stop with the dentist, an infection prevention coordinator can take that pressure off the dentist and be a delegate for all things infection prevention. The rule has been supported by the CDC since its 2003 Guidelines for Infection Control in Dental Healthcare Settings publication.
“Whenever I consult with a practice, one of the things that I recommend that they do is that they assign someone to oversee the safety program,” Daw says. “But when we’re building a culture of safety, responsibility should be doled out to everyone. We want everyone to play a part in infection control and safety at the office for a couple reasons. Number 1 is so that they’re more vested in it. Even if it’s minor, they’re more likely to speak up. And then having everybody participate in monthly team meetings where we bring up the topic of safety and infection control gives them an opportunity to voice their concerns. Having an employer that emphasizes the importance of having a safe work practice is going to help with that, as well. And then of course, ongoing continuing education. I think so often people are taking these online learning systems, and they’re just fast forwarding to the end to take the quiz, answer the questions, and check off that box. So, we’re not learning, and we’re definitely not applying what we’ve learned. I think all those create gaps in the system.”
One of the best ways to avoid problems is through regular, quality training. It’s important to remember that training isn’t just a good idea, it’s required.
“Training is mandatory, as far as OSHA’s concerned,” Wann says. “Training is mandatory every 365 days on bloodborne pathogens. There are other topics as well, sure, but OSHA only has the jurisdiction to cite as it relates to employee safety. Everyone that works in a clinical role needs to be trained on infection control and prevention, and training can be accomplished in a variety of ways, which includes active hands-on training, video training, online training, reading from a book, a workbook, or working with a consultant. There’s a variety of ways to complete training, but what is the most effective for your team? And then I would also suggest that – particularly for dental assistants in states that do not have required licensure for a dental assistant – they need to understand the science to grasp the rationale. They need to understand the science behind it, rather than just, ‘Do what I’m telling you to do’. So, if they understand that they can contract a bloodborne pathogen or transmit it to another patient by not following the protocols properly.”
Training should be a mindful endeavor, not simply something to do just to say that it’s been done.
“The practices where I see the highest risk and liabilities are the ones where we’re treating training and continuing education as just something that we need to check off the box and just get over with,” Daw says. “They haven’t really looked at it for the value that it provides the team and how it can prevent injuries to employees and patients, and risk and liability for the practice. I’m often contacted by practices that say, ‘We want to do something different. We are tired of this online video that we watch’, or ‘We’re tired of the same person with the same information every single year. We don’t feel like we’re getting anything new out of it.’. So as a consultant, I look at what they’ve done previously, and then I see what kind of training do we really need? How can I help build upon what they have?
“There’s not a one-size approach to training,” she continues. “As far as the content goes, certainly OSHA has specific requirements and state dental boards have specific requirements around what must be covered in order for that kind of continuing education.”
No one likes to be told that they’re doing anything wrong, but accepting one’s mistakes is a great first step in correcting those behaviors and creating a safer environment for patients and team members