Don’t Forget the…Infection control details that often slip through the cracks

July 22, 2020

Dental practices are busy places, and while infection control is top of mind right now, there are still tasks that are easy to forget.

Infection control is a simple enough concept: Follow the processes and procedures necessary to keep yourself and patients safe from harm. But there are a lot of moving parts and it’s easy—and common—to overlook some of the details.COVID-19 has made the issue even more complex, throwing some new hurdles into dental professionals’ race to the end of the day. Here are some commonly overlooked areas that could help you maintain a high level of safety.

Source Control

Personal protective equipment (PPE) is, of course, a critical component in an effective infection control strategy. However, a piece of that that is sometimes overlooked is the practice’s overall attitude toward source control.

“Source control is a process where everyone working and entering the office is always wearing a mask of some sort at all times. They are also being aware of social distancing,” Karen Gregory, RN, Director of Compliance and Education for Total Medical Compliance, observes. “Even your front desk people should wear a mask, which can either be a cloth mask or a medical-grade mask. When you are in the clinical area, of course, you’re going to wear the appropriate personal protective equipment. Each worker should want to make sure that they are never in the close proximity of a patient if not wearing PPE, but let’s take that another step further: The clinician is through with the clinical procedure and it is time for lunch. Before COVID-19, you would remove your PPE, perform hand hygiene and go to the break room, but with source control, that clinician should wear a mask, even when they’re not delivering care.”

Whether or not the practice exercises effective source control can have a profound impact on the practice, should the worst occur. Gregory shares stories from two different dental practices, each exercising different levels of source control. One dentist practiced very strict source control, going so far as eliminating the possibility of sharing the break room for eating lunch together. That dentist had a worker who tested positive for COVID, but because that strict source control, they did not have to shut down, because they were able to demonstrate to the health department that they had implemented appropriate measures and protections, thus ensuring that the infection could not spread throughout the practice.

“They lost time talking to the health department, but they did not have to shut the practice down,” Gregory says.

Conversely, a practice on the other end of the source control spectrum wasn’t as fortunate.

“At another practice, a worker tested positive for COVID and they did not wear the appropriate PPE and did not practice source control,” Gregory continues. “That practice was closed for two weeks by the health department, because they had multiple workers who had been exposed. Source control, hand hygiene and surface disinfection is critically important.”

Respiratory Hygiene

Respiratory hygiene is receiving a lot of attention these days, but it is important to remember that it isn’t just the threat of COVID-19 that makes it so important: It is a critical issue to infection control.

“It’s important that we are really skilled at using the high-volume suction. Proper technique and positioning of the suction tip can eliminate 90 percent of aerosols, spatter, and droplets from the patient’s mouth,” infection control consultant and speaker Leslie Canham, CDA, RDA, says. “If a patient has a respiratory virus, it can be aerosolized during patient care and remain in the treatment room for a long period of time.”

There is another component that is just as important to respiratory hygiene as technique: Equipment maintenance.

“Sometimes it’s overlooked and people think that at the end of the day, all you need to do is just empty the chairside trap and run an enzymatic cleaner to clear and deodorize the lines,” Canham says. “That’s a pretty simple step to do, as part of closing out. But the actual vacuum pump, itself, needs to be properly maintained and serviced so it has maximum suction volume. Weekly cleaning of the trap at the pump is important, too. Another weekly task should include disassembling the chairside vacuum valve and cleaning with brushes. Lubricate o-rings and replace if necessary. Refer to the manufacturers’ directions and always wear proper PPE, like utility gloves, protective eyewear, and a mask.”

Respirators vs. Masks

As dental practices reopen, expect to see more N95 respirators in use. But, there are only two ways to wear them: The right way and the wrong way.

“It’s wonderful when we can get the N95 respirators and the face shields and all the other protective gear, but we need a little training on how to don and doff and how to properly maintain our gear,” Canham says. “Sometimes I hear there was a rush to obtain the N95 respirators, and then once they were received, people were wearing them and then having problems later on, like a rash developing on their face, or feeling dizzy, or being unable to breathe.”

In addition to being properly fit-tested, Canham says that training can help prevent some of the issues that come with N95 mask usage.

“You shouldn’t wear makeup or moisturizers underneath respirators; as it may prevent a proper seal and might cause skin irritation,” Canham observes. “You should also take breathing breaks. If you have to wear your respirator for long periods at a time, you should take it off during your breaks and just get some fresh air. Also, making sure that we’re not contaminating ourselves when we don and doff the respirators is an important part of training. I like to see people get together in pairs and don their protective attire with one person watching – to make sure all the steps are taken properly – and then remove their protective attire again with a person watching, maybe holding one of the CDC checklists as a buddy system, so that you can see where you might be making a mistake. Remember that you must perform a seal check every time you don a respirator.”

Knowledge is Power

Effective infection control means brushing up on the skills one frequently practices, along with learning new subjects, topics, and trends. In order to keep up on all these issues, it’s necessary (and often required by regulatory bodies) to conduct consistent staff training.

“Training is critically important, whether it’s new employee training or your annual safety training,” Gregory observes. “I realize that people are trying to play catch-up from when their practices were closed, but it is critical for workers to understand and be reminded of the basics, as it relates to safety. In addition to bloodborne pathogen training, you also need to train your workers on COVID, how to prevent being exposed, and how to identify a patient or a coworker who might be exhibiting symptoms of the illness.”

Getting the correct infection control information is critical for protection of patients and workers.

Gregory says, “Proper training is one of the things that I think people may be skirting, not just because of the cost, but it’s time away from delivering patient care.”

Brushing up on existing rules and requirements should be straightforward enough, but where can practices go for good, reliable sources for new issues, like COVID-19?

“I always reference the CDC and OSHA,” Gregory says. “OSHA has not published any new laws related to COVID. They have published some guidelines, but when OSHA publishes guidelines, even if it’s not a law, it catches my attention. The thing that I think that people are missing when they look at the OSHA guidance is that, if you read the introduction, they very clearly say, ‘There are not any new rules, however if we find that there is an issue, we can site under the General Duty Clause’.

“The CDC, for me, is the resource I constantly monitor, it is more of where I keep my finger on the pulse, for lack of a better word,” she continues, “because they are always looking at the science and they update their guidance to reflect what is happening as a result of learning more and more about this novel disease.”

She recently contributed to a project called, “Best Practices For Infection Control in Dental Clinics During the COVID-19 Pandemic”. The resulting document is a collaboration between OSAP and the DentaQuest Partnership for Oral Health Advancement, with information from the ADA, ADHA, OSHA, and CDC. This document provides a practical checklist for implementing best practices and a very thorough resource/tools section.

“What’s really cool about the resource section is that it’s not just links to websites,” Gregory says. “There’s a description of what you’re going to find when you go to that website which gives you insight so that you’re not just clicking on links and trying to determine what information is on that page. There are also many tools. For instance, there’s an employee screening tool, there’s a patient temperature log, there is a patient screening tool, there is a PPE competency checklist.

“Please know what’s going on in your community as it relates to the number of COVID–19 cases. You may be in a community that doesn’t have a high caseload of COVID-19 infections, but you may be sitting in the middle of a hotspot,” Gregory says. “You’re going to be even more stringent when there’s extreme evidence of community spread than in an area where there may be limited spread of the illness. But you have to keep up with that, because even in those areas where there’s very little evidence of disease, if the right measures are not in place, then those cases will come.”

Infection control has always been a mission-critical component of the dental practice. But COVID-19 made it even more important, and underscores the necessity of not letting things fall through the cracks.

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