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Strategizing infection prevention expenditures is critical for both safety and workflow efficiencies.
Dental practices are in the business of providing patient care, but it’s always important to remember that they are, in fact, businesses. Like any business, to be successful, they have to bring in more money than they spend, and that means keeping a close eye on the practice’s budget.
In addition to planning for categories such as rent, operations, and salaries, dental practices must also establish (and adhere to) an infection control budget. Practices have their own obstacles to negotiate when it comes to staying within that budget. For instance, coronavirus disease 2019 threw a curveball in terms of requiring more personal protective equipment (PPE).
That’s not to say that working within the infection control budget wasn’t already challenging. Dentists look to save money wherever they can but sometimes in a misguided sort of way.
“Dentists can be frugal and, at times, act like MacGyver,” Jonathan Rudin, DDS, MS, MPH, says. Dr Rudin is a safety and infection control consultant at San Diego Healthcare Compliance. “MacGyver was somebody who could rig something out of almost nothing. Dentists can make a big mistake when they try to save product and reuse it when they shouldn’t. They’re probably thinking about their economic situation and realizing, ‘Hmm, I can keep reusing such and such.’”
The big stuff
That budgeting exercise encompasses every part of the practice’s infection control efforts, big and small, but the sterilization center is a primary consideration.
“In my experience, there are not enough dollars set aside for the sterilization area,” Karen Gregory, RN, director of compliance and education for Total Medical Compliance, observes. “The sterilization area can make or break a practice. When designing a sterilization area, if possible, bring in an expert to assist with design and ensure that you have the amount of equipment needed to meet the current demands of the practice and for anticipated growth. Multiple times, I have visited a practice, and instruments are wet when they come out of the sterilizer. When I see that, I think ‘You don’t have enough instruments’ or ‘You don’t have enough sterilization space’ or ‘There’s a problem with the dryer unit drying cycle,’” Gregory observes. “Typically, they don’t have enough instruments or sterilization space. Then they have to evaluate what kind of dollars they are going to invest in growth.”
“I’ve actually never seen an optimal sterilization center,” Dr Rudin adds. “When I give my presentations, I talk about optimal sterilization centers, and that’s something where instruments are brought in after a procedure and follow a linear path.”
Unfortunately, sometimes practices invest their money more in style than substance.
“That even occurs with sterilization centers that the dentists have hired companies to design for them,” Dr Rudin says. “Their centers look like they have been published in an architectural magazine: very attractive to look at but not following a lot of the optimal design recommendations.”
“I’ve been in one practice where they actually have a Starbucks with a barista making coffee,” Gregory says. “That’s great, but if you’re not keeping up with your instrument needs and you have wet packages going out, and those instruments are being used on patients, you may be putting patients at risk of an infection.”
To help process those instruments and avoid other infection control problems, such as the ramifications following a potential failed spore test, the practice might decide to get an extra sterilizer.
“That way, if one fails, and assuming the second one is still working properly, there is a way to maintain the patient schedule by resterilizing all instruments that went through the failing autoclave,” Dr Rudin says. “Of course, this second autoclave can be considered a substantial expense, and there would have to be room for it in the sterilization area. But I would consider it to be a best practice because an office with just 1 autoclave with a failed spore test should stop patient care until the broken machine is repaired and a passing test produced. If they have the failed spore test with just 1 autoclave and they do the right thing by stopping practice, then there can be a tremendous amount of lost production.”
Consumables and PPE
Further down the ledger: budgeting that affects the daily consumables including supplies and PPE. Some dentists, in an effort to save money, channel their inner MacGyver to save money. For instance, Dr Rudin has seen practitioners reuse the pouches used for sterilization: “They will open them carefully and then reseal them using the tape that is used for cassettes, and that is in spite of instructions on the packaging for those pouches that specify one-time use.”
The pandemic has caused infection control budgets to take a big, unexpected hit, especially because of the new requirements for PPE. “The rules of the game have changed right now,” Gregory says. “Because we are in this pandemic situation, hoarding of PPE occurred in some cases at the beginning, because practices, like everyone else, did not know what might happen. Now we are looking at challenges with surface disinfectants. I’ve heard some rumors that there are still some challenges with certain types of PPE, but there is a good tool from the CDC that will actually determine the amount of PPE you will need based on anticipated use.”
In some cases, a shortage of PPE led to a seller’s market, with practices seeing PPE prices go up simply because of scarcity. Fitting needs within the practice’s budget will require not only finding that PPE but also examining how it is used.
“The very best practice would be single use for each item,” Dr Rudin says. “There are trade-offs, because people don’t have a budget or they’re not devoting the budget to single-use of PPE.”
Practices should also take a closer look at their needs and the type of equipment they can use.
“If practices are going to use respirators long term, they may want to look at a more permanent solution, such as the elastomeric respirator,” Gregory says. “An elastomerics respirator provides a similar level of protection as the N95 filtering facepiece respirator, but it’s reusable. If using these devices, you are not having to constantly search for stock and perform a fit test on each new type of respirator. If you purchase this type of respirator, it does cost more up front, but if the use of respirators is long term, then you’re going to more than gain your initial investment in a short period of time.”
Finding the money
When something unexpected takes a chunk out of the practice’s budget, how that expense be met?
“How do we plan for extras in our personal lives? We have a rainy day fund,” Gregory says. Any smart businessperson is going to have rainy day fund. … Look down the road: ‘Is my practice going to need a new or additional sterilizers, or will I need to invest in updated technology? ‘Everybody should be squirreling away some money for that big-ticket item. I don’t think there’s any particular magic to that. That’s just good finances and being prepared.”
Coming up with a few hundred extra dollars for unanticipated PPE needs is one thing; coming up with a few thousand extra dollars for unanticipated equipment needs is something else. What’s the best way to get a doctor to sign off on such a big expense?
“If you knew the answer to that, then you would probably be richer than Jeff Bezos and Bill Gates combined,” Dr Rudin says, laughing. “That’s about motivating people to do the right thing. But there is a field called motivational interviewing, and it’s where the agenda is to motivate by asking pointed questions. I often ask my audiences, ‘How frequently do you think spore testing should be done? What would be the best-case scenario, assuming such a frequency was technically feasible? Once a week? Once a day?’ I finally lead them to the only logical conclusion, which is to use a biological indicator on every load. Think about what happens if you get a failed spore test: ‘How many of the instruments that you’ve run through the autoclave have been used on patients that could have been contaminated?’
“Then you can ask questions like ‘How would it be for you to read about an infection control breach at your practice in the headlines of the newspaper?’” he continues. “There have been articles written about infection control breaches at various practices, whether by intention or just really sloppy methods. Then we can ask practice owners about the impact on the number of patients coming to a practice that was just headlined for committing an infection control breach. Using motivational interviewing, which entails asking questions using the Socratic method, can be a very effective way to motivate practice owners to do the right thing.”
Infection control has always been a critical component in dental practice operations. But, especially in 2020, budgets must reflect that importance.
“Right now, infection control is even more important than it’s ever been,” Gregory says. “The reality is that we have to pay attention. We have to be diligent in every situation. We can’t afford not to be.”