Looking at how to handle challenging infection control tasks and the variability in how we can optimize these tasks moving forward.
Dental practice infection control encompasses tasks from disinfecting operatory chairs to instrument sterilization to chores as tedious as recordkeeping. While some things require following a step-by-step procedure, other duties need not be so rigorous. Some infection control tasks allow for wiggle room and can be performed however a practice sees fit – and that provides an opportunity for streamlining.
Disinfection Best Practices
Disinfection, for instance, is 1 task that allows such latitude.
“There’s nothing that says you have to do it 1 way or another. You can either do barriers or wipe it down,” Lisa Kane, DMD, says. Dr Kane is a speaker and infection control consultant at Dental Office Compliance of New England. “So obviously, an easier thing to do is throw a big cover on a chair rather than to wipe it down each time, because if you wipe every time, then you have to wipe down all the nooks and crannies, and, if there are controls on the chair, you want to wipe those down, too.”
Some of the variability in disinfection methods comes down to whether the practice opts to use disinfectant sprays or wipes.
“I often see that people are confused about when to use wipes or sprays,” Jonathan Rudin, DDS, MS, MPH, says. Dr Rudin is a safety and infection control consultant at San Diego Healthcare Compliance. “While they both can be the same chemicals, there are more indications for wipes than sprays. Using spray disinfectants require more respiratory protection than wipes.”
The decision of whether to use a wipe versus a spray is driven by what item is being disinfected.
“That’s 1 of the areas of confusion. People will grab whatever is closest at hand to disinfect a certain item or surface. Instead, they should choose a spray or a wipe that is the most appropriate for the task,” Dr Rudin says. “Wipes are typically used for smooth, impervious surfaces, whereas sprays would be used for disinfecting irregular surfaces like impressions and dental appliances.”
While there is no mandated way in which to disinfect, that doesn’t mean practices have complete freedom to disinfect anyway they like. There are still rules that must be followed, and they are product-dependent, meaning each product has its own required contact time.
“You have to disinfect for the amount of time that the disinfectant prescribes [called] the kill time,” Dr Kane observes. “Everything has to stay wet for that amount of time. You can’t pick and choose when you’re going to make it really clean and when you’re just going to make it so-so clean.”
“For a given disinfectant, there’s a specific contact time or kill time that is required before using that surface again,” Dr Rudin adds. “Fast-moving practices may wipe a surface dry without waiting for the full kill time to elapse. In so doing they’ve just negated the action of the disinfectant. My encouragement is to choose a product that has a shorter kill time so they can turn over a room quicker between patients.”
The aforementioned infection control procedural wiggle room doesn’t exist in sterilization. Instruments must be processed in a specific way. However, the overall workflow can be fine-tuned for ease and efficiency.
“Sterilization should definitely be by the book,” Dr Rudin says. “Having at least 2 autoclaves is recommended, because if 1 fails, then the practice will be without instruments. And if the spore testing of the autoclave reveals that it is not functioning properly, then it’s supposed to be repaired or replaced. The instruments that have been processed since the last passing spore test are not considered sterile. Those instruments need to be pulled out of circulation. So, if they don’t have a backup autoclave, or a second one that they use simultaneously, then they’re essentially out of sterile instruments.”
Regrettably, the lack of sufficient instrumentation seems to be commonplace.
“There’s almost no practice I know of where all the instruments that [have been autoclaved] after the last passing spore tests are kept out of use until they get the validation of the next passing spore test,” Dr Rudin observes. “That’s because practices don’t maintain an inventory of so many instruments, as they are so expensive, but that’s actually the proper way to operate. Why would you wait for a passing spore test only to find out your autoclave has failed its spore test? Then you realize that you’ve used half the instruments that came through that autoclave since the last passing spore test. It is often a surprising concept for practices to recognize that they have been using non-sterile instruments. They had not thought about it before our discussion.”
If a practice’s instrument reprocessing efforts seem to be error-prone, it’s time to reevaluate their methodology.
“It has to be done the right way and everything has to be documented the right way, but there are easier ways to do it,” Dr Kane adds. “If your instruments are always sticking out of your bags and poking holes in them and you’re having to reprocess them all the time, maybe you want to think about using cassettes. You have to label your bags, but you can also color code them. It’s really important to carry things in a covered, closed container from the operatory to the sterilization area. You’re supposed to do that per the Centers for Disease Control (CDC), but it does make things more efficient if you just throw everything in this bucket, put the lid on it, and then carry it. That way, you don’t have to worry that something’s going to fall out or you’re going to get poked on the way, versus trying to balance everything on an open tray.”
Variability in Personal Protective Equipment
How much variability exists in terms of personal protective equipment (PPE)? While everyone should know the correct way to put on gloves, masks, and a gown, sometimes that is not the case. Taking the time to practice donning and doffing PPE helps ensure that everyone is doing it properly and effectively.
“From the beginning of COVID-19, I was telling everyone to have PPE parties,” Dr Kane says. “You’re supposed to have the donning and doffing technique posted in your office, and I think you just have to really pay attention to it and practice it. The better you get with PPE, and putting it on in the right order, the better you are. People put on their gloves and then put on their glasses or their masks. You never touch your hair or anything on your head with gloves. All that stuff goes on before gloves, and then you always wash your hands before you put your gloves on. Then, when you have gloves on, the only thing you’re touching is either the patient or patient care items. The more you practice, the better you’ll be at it, just like anything.”
It isn’t just the practical, hands-on infection control tasks that can be streamlined. Recordkeeping is an important part of the infection control process and an area that can be optimized.
“For our clients, we make all their recordkeeping digital,” Dr Kane says. “You have to do the logs in your office, but you could make them easy to do; maybe you do them room-specific. For example, the sterilization area has 1 log and operatories have another log. Maybe you break them off between daily, weekly, monthly, yearly, and you just you try to get everything organized. I’ve noticed a lot of people have a logbook that has many pages of different things that they’re supposed to do. And I think if you put everything on the same page for all the things you’re supposed to do at a certain time, then it’s easier to do, but you do have to document.”
Remember, recordkeeping isn’t just a helpful, albeit tedious, task. It is also federally required.
“People think everything’s a pain in the neck with recordkeeping, but that’s important with the governing bodies,” Dr Kane adds. “They really want you to have recordkeeping of infection control policies and procedures, but also documentation that you’re actually doing what you say that you are, and that you’re taking care of your equipment. The more you take care of it, according to the manufacturer’s instructions, the longer your equipment lasts for you. And that protects your practice, too, in case something does go wrong. If you have that paper trail, that helps you.”
Infection control optimization isn’t an issue of cutting corners. Obviously, patient care and safety are the most important things. However, being able to efficiently operate within the confines of infection control procedures will save the practice time and improve safety for both the patient and clinician.
“I wouldn’t suggest cutting corners in any way,” Dr Rudin says. “I see it enough: Cutting corners, even by people that think they’re complying with everything, or want to be compliant, or want to be perceived as being compliant. Unfortunately, they’re not operating by-the-book as what you might expect or hope.”