Striving for infection prevention perfection can lead to safety risks if instructions and details are overlooked.
The risks of poor infection control are well-known:harmed team members, injured patients, and damaged professional reputations.But striving for infection prevention perfection can come with its own set of dangers, especially if team members are hasty and overlook simple safety details.
One area of concern is that the practice’s right hand may not know what its left hand is doing. That is, the person responsible for buying infection control products and supplies may not know what the practice needs and how those supplies are best used.
“You’ve got people that do the disinfection, these are front-line dental assistants, hygienists and other team members,” Dr Douglas Risk, DDS, says. Dr Risk is the Compliance Manager and private practitioner at Tidewater Dental in Southern Maryland, serves on the Executive Board of Directors for OSAP, is a Diplomate of the American Board of General Dentistry, and is a Fellow of the International College of Dentists. “There may also be people that do the ordering and then someone else that recommends a product. Someone might even go to a meeting and see all the infection control vendors, and one manufacturer says, ‘This is the cheapest, easiest, and most effective product you can buy. Oh, and by the way, I’ll give this great big coupon for a year’s supply.’ So, that disinfectant comes into your office, but the person who bought it may not have gone through the entire thought process to know what you can use it on, what it’s designed for, what the precautions are – do you wear exam gloves? Do you wear heavy duty utility gloves? Can you use it without a mask? Do you need a respirator? Does it give off certain fumes that actually only should be used under a hood?”
Ensuring that everyone understands the role of infection control products helps diminish all safety concerns.
“How you mitigate risks is where research is needed,” Dr Risk advises. “We all need to read the instructions for use and the safety data sheet and follow those recommendations explicitly, according to the type of exposure to that chemical. For instance, the safety data sheet may say to use a different type of PPE, but that PPE may be for larger spills or greater exposure. If you drop a gallon of it in the hallway, what happens when there are more fumes than a couple of spritzes in a dental operatory? If the manufacturer doesn’t give you the information in the instructions – for instance, how to use it safely – then that may not be the best product to use. And then don’t forget to train the staff. If the users are not the ones who chose the product, then they should be trained on how to use that product safely. And when do you use it, how much to use? Do you spray it and leave it? Do you spray it, wipe it off? Spray something else to disinfect? Do you spray, wipe it, and then spray it again?”
The product’s effectiveness also demonstrates the notion of safety. If the product is not effective, it’s not providing the safety for which it is intended.
“Since wipes came on the market, there’s been a misconception that this is just a one-step procedure,”Mary Bartlett, President SafeLink Consulting says. “Always read the instructions on the label. And, in most cases for liquid disinfectants and wipes, the instructions state to apply on a pre-cleaned surface. That means to clean the surface first and then apply the chemical. When more liquid disinfectants were being used and applied in a spray method, the steps were to spray-wipe-spray. That means to spray on the chemical, wipe it off, and then spray it back on and let it dry. With wipes, the method should be the same, so if a practice prefers a wipe, then use a fresh wipe to wipe all of the surfaces, dispose of the wipe, and get a fresh wipe to apply the chemical.”
There is concern about a product’s potency in relation to its safety and potential to harm those using it. How does the practice find the sweet spot between the product’s effectiveness and its safety?
“That’s a huge problem, because everyone’s sweet spot could be different,” Dr Risk says. “I might have the ability to buy a product that has a very short contact time, because I have a very high-volume practice and a high-dollar bottom line, and so, the minutes count. Whereas, I could buy a half-price product with a three-minute kill-time and just take five extra minutes to turn an operatory around. I would not be able to tell somebody that one of those products is ideal, because they are very similar, they just have a different time and cost aspects. So, the best thing that I could say is definitely talk to manufacturers, but also do the research in the class of disinfectant you’re looking for. And there’s some pretty good resources from the EPA. The EPA actually has a list of intermediate-level disinfectants, List B, and that list has contact time and chemistry, which helps in the decision process. Then, you can also cross reference that list with the list of COVID-effective disinfectants, List N, and you can get a pretty good idea of what’s out there and what is effective. You can narrow the choices down to the ones that are available and that are most appropriate.”
Watch your hands
Team members run the risk of injury when preparing instruments for reprocessing and should be mindful of procedure.
“The risk of a sharps injury is also possible when removing debris from instruments prior to packaging them for sterilization,” Bartlett says. “The risk is in the handling of the dirty instruments during this procedure. As recommended by the CDC, the team member should wear puncture-resistant, heavy-duty utility gloves. Also don’t reach into trays or containers holding sharp instruments. Use of a strainer-type basket to hold the instruments is best to remove the items from the containers. Of course, always wear full PPE which includes a mask, protective eyewear or face shield, gloves, and a gown or jacket.”
The necessity for good hand hygiene is nothing new, but efforts to ensure that hands are properly cleaned should be done properly and conscientiously.
“During this pandemic, hand hygiene has been in the forefront as the single most critical measure for reducing the transmission of organisms, and that is not only to ourselves but to patients,” Bartlett says. “Dentists and team members should wash their hands prior to gloves and after removing gloves. Gloves can tear, which could allow microorganisms to enter the glove. Best not to have long fingernails or wear jewelry that can tear the gloves. The CDC recommends that the method used for hand hygiene take into account the type of procedure, the degree of contamination, and the desired persistence of antimicrobial action on the skin. When wearing surgical gloves, CDC recommends using a surgical hand antisepsis that substantially reduces microorganisms on intact skin. The CDC’s 2003 Guidelines for Infection Control in Dental Health-Care Settings provides a table indicating hand hygiene methods for routine handwash, antiseptic handwash, antiseptic hand rubs, and surgical antisepsis.”
As they say, the devil is in the details, and there are plenty of little things at the practice that could put one at risk when trying to be safe.
“Receiving dental prostheses from a dental laboratory are often overlooked in the cleaning process,” Bartlett says. “There seems to be a misconception that all dental laboratories disinfect crowns, bridges, dentures, etc. prior to shipping them to the dental client. The state of Texas does require dental laboratories to disinfect these items prior to packaging them for shipment, however, that requirement is not nationwide. The best practice, even if it has been disinfected by the dental laboratory, is to unpackage the item and disinfect it or sterilize it if is considered a critical, semi-critical, or non-critical item. Some items, such as burs and implant components, are packaged as sterile, but ensure the packaging indicates that it is sterile, rather than presuming it is sterile.”
Nitrous oxide systems can also present itself as a source of trouble, but that can be mitigated by utilizing single-use tubing.
“It’s also important now, because of COVID-19, for you to review the nitrous oxide-delivery system manufacturer’s manual for cleaning, disinfection and/or sterilization of the tubing that connects to the nose piece,” Bartlett says. “Some practices use single-use tubing, others sterilize the tubing, and in some cases the only procedure may be to run soap and water through the tubing. Some of my clients have retrofitted the delivery system to accept disposable tubing and have found that the initial investment is worth it as it saves costs in the long run by using disposables for tubing and the nose pieces.”
Be sure to understand the varying infection prevention protocols required of applications throughout the practice.
“Surface disinfectant, the suction lines, and the dental unit water lines all need different protocols to be effective at cleaning,” Dr Risk says. “And those three areas are very important in the disinfection of a dental practice. So, if I were to recommend someone do some research, I would look at those three areas as starting points to make sure that they are being effective at actually doing the things that they want to do, which is clean and disinfect those areas.”