The COVID-19 pandemic has been full of hard lessons for healthcare providers. But improved infection control has been a silver lining.
According to motivational posters and social media memes, the Chinese word for “crisis” is the same as the word for “opportunity.” This is all well and good when you’re at the gym trying to power through a difficult set or when you need inspiration during a long meeting, but the Chinese words for “crisis” and “opportunity” are not the same. However, there is a lesson to be learned: Use dark moments as an opportunity to search for a silver lining. As tough as the pandemic has been, there have been unexpected opportunities, and infection control is one place where a silver lining can be found.
Practices received ample guidance from organizations such as the Centers for Disease Control and Prevention (CDC), the America Dental Association (ADA), and the Occupational Safety and Health Administration (OSHA). The intention of that guidance was, of course, to keep practices open and maintain the safety of patients and team members, but was all of it helpful?
“Initially, they were constant,” said Lisa Kane, DMD, with a laugh. Dr Kane is a speaker and infection control consultant at Dental Office Compliance of New England. “The ADA had a ton of updates. CDC and OSHA also had things that I constantly paid attention to. The CDC is still changing things every day. What people learned is that you have to pay attention because the guidelines are constantly changing. Before, I feel like everything was status quo, and now you can’t really rely on that.”
Perhaps one of the most inescapable pieces of advice was to be mindful of airborne droplets.
“Practices in dentistry have benefited from the pandemic in that people are more aware of the need to capture sprays and droplets as they’re created during a dental procedure,” Jonathan Rudin, DDS, MS, MPH, observes. Dr Rudin is a safety and infection control consultant at San Diego Healthcare Compliance. “To me, that’s one of the great take-home lessons. I recommend using engineering controls like rubber dam and high-volume evacuation (HVE) to eliminate the airborne pathogens as close to the source as possible, and then using other barriers to prevent pathogens not captured near the source. These barriers include face shields, eye protection, and masks—all used in combination.”
If one picture were to capture the essence of the pandemic, it would be of someone wearing a mask—patient or clinician.
“Virus sizes can range from about 0.02 to 0.5 µm,” Dr Rudin observes. “Those sizes are generally too small to be filtered by conventional masks. Assuming that free viral particles are suspended in the air we breathe, then wearing a mask is like throwing sand at a chain-link fence and expecting the bulk of grains…will not pass through. We’ve got to do as much as we can but within reason. Wearing a tight-fitting N95 mask, for example, imposes a challenge [on breathing].”
Is there a solution for those who may find N95 masks restrictive?
“There are definitely some challenges associated with wearing respiratory protection. These include the physical demands of pulling air in and expelling it. It also includes the hazards of rebreathing expelled carbon dioxide and the pathogens we ordinarily rid ourselves of each time we exhale,” Dr Rudin says. “And these pathogens can be concentrated and deposited on the inner surface of the mask throughout the day, especially if people are not discarding the mask after a single patient. With shortages of masks, primarily early on in the pandemic, reuse was a way to extend the life of the masks. Such reuse is not recommended and actually a violation of the FDA [Food and Drug Administration]-approved instructions for use for the mask. So masking is a real controversial point.”
For those who have a difficult time wearing a mask, a powered air-purifying respirator (PAPR) can be a good option.
“To protect dental care personnel from pathogens that do make it past the HVE system, I recommend the PAPR system, which looks kind of like a hazmat suit,” Dr Rudin says. “There are 2 varieties: loose-fitting and tight-fitting. The loose-fitting type does not require fit-testing and is the only type of respiratory protection that allows someone with a mustache and beard to be protected in any way. Trying to get a good seal when there’s facial hair is virtually impossible.”
PAPRs come with downsides, of course. First, they are expensive. And second, they can interfere with communicating with your patients.
“Patient interaction can be inhibited by the PAPR,” Dr Rudin explains. “They provide a lot of protection, but when you’re talking to your patients and they see you essentially dressed in a hazmat suit, [they] might wonder, ‘Well, if the practitioners are protecting themselves to the extent that I see right here, what am I getting exposed to while having my filling replaced?’”
Back to basics
Perhaps the best thing to come of the pandemic is not that anything new was learned, but that attention was refocused on the infection control efforts that practices should have been making all along.
“It made everyone aware of infection control policies,” Dr Kane says. “I think it…brought everything to the forefront. A big thing, initially, was [that] everyone kind of cleared out their operatories. There were no open things on the counter. A lot of people, in the past, used to have single-use items like cotton rolls or gauze…out where they could get contaminated. And that seems to have stopped, significantly, which is really good. Another thing is that people focused on handwashing a little bit more and making sure they do it before they put their gloves on and after they take their gloves off. Also, not coming to work when you’re sick. That was something you always were supposed to do. But I think that’s become more the norm now, whereas before I think people just tried to suck it up.”
The pandemic has provided teachable moments for Dr Kane and her clients.
“When I do infection control lectures, the first thing I say is, ‘This is all pre–COVID-19,’” Dr Kane notes. “None of this stuff is COVID-19–related, except now we’ve upped the PPE [personal protective equipment] a little bit with N95s, but everything else is stuff that everyone is supposed to be doing.
“A big thing too is that people didn’t have written plans and protocols before,” she continues. “What made people aware is if someone had COVID-19 or had a symptom of something, you’d look at the policy and…say, ‘What do we do, according to this?’ Before, no one really had written documentation or updated documentation as far as OSHA books and policies and that sort of thing. Now, I think it’s been good for the infection control world because it’s getting people to do the things…they should’ve been doing before.”
One more thing
For all the lessons learned and best practices underscored, Dr Rudin reminds us that there are other habits to keep team members healthy, as we head into the third year of the pandemic.
“Good exercise can boost your immune system,” he says. “That can include cardio exercise and weight lifting. I hope that exercise will tie in with people’s New Year’s resolutions. I would add that getting plenty of sleep and good nutrition can also contribute to a vibrant immune system.”
Dr Kane advises having an outside person assess the practice.
“It would do every practice well to have someone do a walkthrough of their office, or a virtual walkthrough because even though there are so many things that people are doing, there are still so many things that even good offices are missing,” she observes. “So I think that having someone come in with a new set of eyes is a really good idea. They can evaluate and see what you’re doing. Maybe you’re doing a fantastic job and everything’s perfect and you’re good, but maybe there are a couple things that you can tweak and make it a little safer for the patients and the staff.”
That inspirational chestnut about the Chinese words for “crisis” and “opportunity” may be false, but the pandemic has still provided good motivation to find a silver lining in the dark cloud.