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Management of infection control in dental

practice

A. Smith

a,

*

, S. Creanor

b

, D. Hurrell

c

, J. Bagg

a

, M. McCowan

d a

Infection Research Group, University of Glasgow Dental School, Faculty of Medicine, Glasgow, UK

bBiostatistics & Epidemiology Group, University of Plymouth, Tamar Science Park, Plymouth, UK c

HealthCare Science Limited, Bury Mead Road, Hitchin, UK

d

Infection Control, Golden Jubilee National Hospital, Clydebank, UK

Received 24 October 2008; accepted 7 November 2008 Available online 21 January 2009

KEYWORDS Cleaning; Decontamination; Dental instruments; Medical devices; Quality management systems; Sterilisation

Summary This was an observational study in which the management pol-icies and procedures associated with infection control and instrument de-contamination were examined in 179 dental surgeries by a team of trained surveyors. Information relating to the management of a wide range of infection control procedures, in particular the decontamination of dental instruments, was collected by interview and by examination of practice documentation. This study found that although the majority of surgeries (70%) claimed to have a management policy on infection control, only 50% of these were documented. For infection control policies, 79% of surgeries had access to the British Dental Association Advice Sheet A12. Infection con-trol policies were claimed to be present in 89% of surgeries, of which 62% were documented. Seventy-seven per cent of staff claimed to have received specific infection control training, but for instrument decontamination this was provided mainly by demonstration (97%) or observed practice (88%). Many dental nurses (74%) and dental practitioners (57%) did not recognise the symbol used to designate a single-use device. Audit of infection control or decontamination activities was undertaken in 11% of surgeries. The ma-jority of surgeries have policies and procedures for the management of in-fection control in dental practice, but in many instances these are not documented. The training of staff in infection control and its documentation is poorly managed and consideration should be given to development of quality management systems for use in dental practice.

ª2009 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. Address: Infection Research Group, Level 9, Glasgow Dental Hospital and School, 378 Sauchiehall Street, Glasgow G2 3JZ, UK. Tel.:þ141 211 9747; fax:þ141 353 1593.

E-mail address:a.smith@dental.gla.ac.uk

0195-6701/$ - see front matterª2009 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2008.11.026

Available online at www.sciencedirect.com

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Introduction

Infection prevention and control are key elements in providing a safe environment for patients and staff within a dental practice.1e5

Recent media in-terest and publications have created heightened concern.6The discovery of vCJD and the potential for spread of not only this agent, but also blood-borne viruses and other infectious agents, via inad-equately decontaminated instruments has also led to increased concerns.

The benefits of a well-managed infection prevention and control system in any premises delivering healthcare have become both a public and political prime concern.5,7 An appropriately managed infection prevention and control service should share the responsibility across the practice staff whilst maintaining accountability, and provide quality assurance that instruments are effectively cleaned and sterilised. There are many sources of infection control advice available, which can be adapted and reconfigured to improve the service delivery and assist the dental practice in delivering quality infection control in an appropri-ately risk-assessed environment.1,2,8e11

The British Dental Association (BDA) Advice Sheet A12 on infection control in dentistry pro-vides broad advice on the roles and responsibili-ties in relation to management of infection control.1 All members of the dental team must know who is responsible for ensuring that certain activities are carried out and to whom they should report any accidents or incidents. The individual practitioner must ensure that all members of the dental team understand and practise these proce-dures routinely, have been appropriately trained and have demonstrated competence in particular procedures. This must be documented. There are also technical standards for Local Decontami-nation Units (LDUs). A senior member of staff with documented responsibilities for infection control and the decontamination of dental instruments must be nominated to manage these activi-ties.9,12e23

A job description should set out these responsibilities to manage infection control in ac-cordance with legal requirements and national standards.9,12e22

The surgery should also have documented defined accountability for infection control and the various stages in decontamination of dental instruments (including device acquisi-tion and disposal). The surgery should have written policies and procedures that define, docu-ment and control the various stages involved in managing the risks of infection. These should be readily available to all relevant staff in a surgery.

There should also be access to current legislation and guidance relevant to infection control. This requires appropriately trained staff and record-keeping systems that are regularly audited.9

Previous attempts at investigating management of infection control in dental practice have relied on questionnaire studies with their attendant shortcomings.23In order to address these shortcom-ings, we have previously described a methodology for a large observational study of decontamination of dental instruments in general dental practice.24 The aim of this study is to report in detail the management of infection control and instrument decontamination in a large cohort of dental prac-tices that were visited between January 2003 and March 2004.

Methods

Survey methodology

This has previously been reported in detail.24 In brief, the study population comprised all general dental practitioners in Scotland with a National Health Service (NHS) list number (N¼837). This list was the basis for randomly selecting practi-tioners to survey.

A two-stage proportional stratified random sam-pling method was used to identify which surgeries were to be surveyed. First, practices were ran-domly selected in proportion to the distribution of practices within each of the health boards. Then, if there were more than one dentist within a selected practice, simple random sampling was used to identify a single dentist within the selected practice to be approached. The surgery that the dentist worked from and its associated decontamination facilities were the subject of the survey. A total of 184 surgeries were surveyed.

Data collection

Each surgery was surveyed by a team of two, an infection control/decontamination expert and an experienced dental practitioner. The survey team interviewed the dental practitioner and dental nurse, reviewed documentation relevant to the survey and recorded the physical layout of the premises. The decontamination processes, policies and procedures available to the dental surgery staff were viewed directly by a member of the survey team. All relevant data were recorded on to data collection forms prepared for automated

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reading.24The survey visits ran from January 2003 until the end of March 2004.

Technical requirements and guidance

The data collection forms for the survey were based on a number of technical requirements and guidelines.1,12e20In addition, data were collected

to examine compliance with a number of legal re-quirements designed to ensure that appropriate facilities and management processes were in place in surgeries. These include the Consumer Protection Act, The Medical Devices Regulations 2002, The Health and Safety at Work etc. Act 1974 and Man-agement of Health and Safety at Work Regulations 1992.12,13,25,26

Results

Data were available from 179 surgeries for analy-sis. In the surgeries surveyed, the number of staff that worked in the selected surgery was 1e9 for dental practitioners, 0e1 for community dental officers, 0e1 for vocational trainees, 1e7 for dental nurses, 0e5 for trainee dental nurses, 0e5 for hygienists, 0e4 for receptionists and 0e4 for cleaners. Infection control was included in the job description of 13% of dentists and 46% of dental nurses. In 7% of practices there was one or more member of staff whose sole or principal duty involved the cleaning and sterilising of dental instruments. In those practices without a dedicated member of staff these tasks were undertaken by dental nurses. Additionally, 42% of dental practi-tioners, 38% of dental hygienists and 2% of ancillary staff undertook decontamination of in-struments. In no surgery were dental technicians undertaking decontamination of instruments.

Infection control management and

decon-tamination policies

A policy is used to describe a statement of intent and/or objectives. Of the 70% of surgeries with a management policy for infection control avail-able within the practice, only 50% were docu-mented. With regard to policies for infection control, the BDA Advice Sheet A12 was available in 79% of the surgeries visited, of which 45% used the BDA Advice Sheet A12 unmodified as their policy. In 16% of surgeries there was effective policy control of infection control documentation (for example unique numbering of policies). Al-though 73% of surgeries had a system in place to ensure that all staff were kept up to date with

changes in policy, only 26% had a documented system for ensuring that this took place. Within the practice, 51% had a monitoring system to ensure that infection control procedures were in line with current guidance.

In 23% of surgeries there was a policy giving guidance on when to choose single-use as opposed to re-usable instruments, when both were com-mercially available. For 47% of surgeries there was a policy on the re-use of devices labelled as single use, of which 37% specified that re-use was never allowed. Re-use of matrix bands was undertaken in 34% of surgeries, re-use of endodontic files was undertaken in 87% of surgeries and re-use of impression trays was undertaken in 59% of surger-ies. Fifty-one percent of surgeries had a written policy describing the method of cleaning to be used for re-usable medical devices.

Infection control procedures and work

instructions

Procedures and work instructions provide step-by-step instructions of how a particular task is to be carried out. Within the surgeries surveyed, 89% had infection control procedures, of which 62% were documented.

Infection control staff meetings

Regular specific infection control meetings were held by 16% of practices. Of these, 22% had annual meetings and 56% had meetings only when required. At routine staff meetings, 89% discussed infection control, but only 46% of staff meetings were minuted and 48% recorded de-cisions taken.

Staff training

The ability of staff to recognise safety symbols on medical devices is good practice.27The knowledge of dental staff in the recognition of common sym-bols is summarised inFigure 1.

Seventy-seven per cent of staff had received specific infection control training. For the dental practitioners that had received such training, 74% had attended Section 63 postgraduate courses organised by NHS Education for Scotland. For the dental nurses who had received specific training, 66% had been taught at Scottish Vocational Qual-ification (SVQ) level. In 31% of surgeries there were documented training records for each member of staff and training was reviewed on a regular basis in 58% of surgeries.

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Sixty-two percent of surgeries had procedures in place to ensure that staff training occurred in the documented procedures used as part of their routine work activity on dental instrument de-contamination. Compliance with these procedures was formally monitored in 21% of surgeries. Staff training in decontamination was provided mainly by demonstration by other practice staff (97%) and/or by observed practice (88%).

Hand washing

Hand washing is a key component of infection control policies. A procedure for hand washing was available in 53% of surgeries, of which 32% were documented. Hand washing was part of training for all practice staff in 41% of surgeries and in 53% of surgeries for clinical staff only. The majority of surgeries (84%) used surgical hand scrub alone and/or alcohol gels/solutions (22%), liquid soap (20%) and bars of soap (4%). Re-usable nail brushes were present in 22% of surgeries.

Waste disposal

In 93% of surgeries there was a waste disposal policy, of which 53% were documented. Puncture-proof containers were used for the disposal of sharps in 99% of surgeries, all of which were compliant with BS7320. Partly used local anaes-thetic cartridges were disposed of in a sharps box (63%), special waste box (24%) or yellow waste bag (5%). Extracted teeth were disposed of in a yellow waste sack (58%), orange waste sack (11%), sharps box (8%) or black waste sack (1%), or sent to a dental school to be used for training purposes (25%).

Traceability

No surgery kept records that enabled traceability of instruments to the patient. However, 1% of surgeries kept records that enabled tracing of instruments through the cleaning and/or the sterilisation process. Most surgeries (99%) decon-taminated equipment prior to sending it for repair, of which 77% issued a written statement with the equipment to state that this had been performed.

Audit of infection control policies and

procedures

Audit of infection control activities had been undertaken in 11% of surgeries, of which 54% fed back results to all staff and 46% defined timescales for remedial action.

Staff health and safety

All staff had access to personal protective equip-ment. Access to individual items of protective equipment occurred in 97% of surgeries for eye protection, 98% for surgical masks, 99% for gloves and 35% for waterproof aprons. The majority of surgeries (98%) had no contract for laundering of staff uniforms, which were usually processed in a domestic washing machine (99%).

All staff involved in the decontamination of dental instruments had been offered immunisation against hepatitis B. However, staff in 59% of surgeries commenced work decontaminating den-tal instruments prior to completing a full course of hepatitis B immunisation. New staff had a health screen in 49% of surgeries.

In relation to the Control of Substances Hazard-ous to Health (COSHH) regulations, 69% of surgeries had safety data for each chemical used. Sixty-one percent of surgeries had a safety policy to deal with any spillages or leakages of chemicals which took into account the potential chemical or microbio-logical hazards. In 42% of surgeries, manufacturers’ instructions were followed when decontaminating dental instruments used in the surgery.

Discussion

When compared with earlier literature this survey has shown much improvement in certain aspects of infection control and instrument decontamination in dental practice. For example, the availability of personal protective equipment, such as gloves and eye protection, has increased over the last decade.23 It is also reassuring that all practices

0 5 10 15 20 25 30 35 40 45 50

Dental nurse Dentist

Figure 1 Recognition of single-use (white bars) and use-by (black bars) symbols by dental staff.

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offered hepatitis B immunisation to all new staff, although many staff were not fully protected when they first commenced clinical duties. The main finding of this study is the gap between staff perception of working to infection control policies, procedures and work instructions and the docu-mented availability of these papers. Many surger-ies had access to, and used, the BDA Advice Sheet A12 which, although providing broad principles, is insufficiently detailed to provide pro-cedures and work instructions for many aspects of infection control and decontamination of instru-ments. This is highlighted by the lack of knowledge of the dental team on interpretation of the ‘single use’ symbol on medical device packaging. The de-ficiencies in the management of infection control were also highlighted by the lack of specific infec-tion control meetings, document control and audit of infection control practices. This probably reflects the lack of training and education in the application of quality management systems and the small number of staff in a dental surgery.

In regard to hand hygiene, it is apparent that the profile of this basic measure was not as high as it might have been and, if in place, was outdated.8 Just over half of staff incorporating hand washing into their training and the majority of surgeries used surgical hand scrub for routine hand washing. In relation to waste disposal, the majority of practitioners were undertaking appropriate segre-gation and disposal of clinical waste. The range of methods for disposal of partly discharged anaes-thetic cartridges and extracted teeth reflects the lack of clear guidance and changing legislation in this area; it is not appropriate to dispose of used cartridges in yellow plastic sacks.

The study has shown that there is no traceabil-ity of decontaminated instruments through the cleaning or sterilisation process. In the event of an adverse incident these records would do much to protect the practitioner and limit subsequent investigations. The use of batch-related records for instrument decontamination as part of a quality management system would be a sufficient reassur-ance since it seems unlikely that a fully traceable system linking individual instruments to patients is viable at the present time for dental practice.

Many practices lack a properly managed infection control system. The risks clearly identi-fied in this study could be rectiidenti-fied by the appli-cation of an appropriate quality management system.28e30 Local decontamination units do not

require a system as extensive as that applied in central decontamination units but should have documented policies, procedures and records for all the key elements of the decontamination

process.9,31,32 Such a quality management system should also be applicable to other aspects of den-tal practice and not specifically implemented just for infection control. However, it is essential that whichever quality system is adopted it should consider the relatively small numbers of staff involved and ensure that generation of documen-tation is not an end in itself but should be a value-added activity. Dental practices should also give consideration to adoption of a hazard analysis and critical control point (HACCP) type ap-proach.10,11 This system has been adapted for use in other small professional and industrial environ-ments, such as food premises, together with a sys-tem of independent inspection. Application of the HACCP system is also compatible with the imple-mentation of total quality management systems, such as the ISO 9000 series.

In conclusion, the deficiencies identified in this study can be rectified by changes in core training at undergraduate level and within the continuing professional development of both dentists and dental care professionals. Expert guidance is needed to institute the introduction of an appro-priate quality management system in dental practice if long-term investments and improve-ments in risk reduction are to be maximised.

Conflict of interest statement

None declared.

Funding sources

Study supported by a grant from the Scottish Executive Health Department.

References

1. British Dental Association.Advice sheet: infection control in dentistry A12. London: BDA; 2003.

2. Centers for Disease Control and Prevention. Guidelines for infection control in dental health care settings. Morb Mortal Weekly Rep2003;52:RR-17.

3. Bentley EM, Sarll DW. Improvements in cross infection con-trol in general dental practice.Br Dent J1995;179:19e20.

4. Bagg J, Sweeney CP, Roy KM, Sharp T, Smith A. Cross infec-tion control measures and the treatment of patients at risk of Creutzfeldt Jakob disease in UK general dental practice.

Br Dent J2001;191:87e90.

5. Scottish Executive Health Department, Healthcare Associ-ated Infection Task Force.The NHS Scotland code of practice for the local management of hygiene and healthcare associ-ated infection. St Andrew’s House, Edinburgh: SEHD; 2004. 6. Roy KM, Ahmed S, Cameron SO, Shaw L, Yirrell D,

Goldberg D. Patient notification exercise following a den-tist’s admission of the periodic use of unsterilized instru-ments.J Hosp Infect2005;60:163e168.

7. Department of Health, England. Getting ahead of the curve: a strategy for combating infectious diseases. London: Department of Health; 2002.

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8. Pellowe CM, Pratt RJ, Harper P,et al. Evidence based guide-lines for preventing healthcare-associated infections in primary and community care in England. J Hosp Infect

2003;55(Suppl. 2).

9. Health Protection Scotland, Scottish Government. Local decontamination units: guidance on the requirements for equipment, facilities and management. Edinburgh: Stationery Office; 2007.

10. Hulebak KL, Schlosser W. Hazard analysis and critical con-trol point (HACCP) history and conceptual overview. Risk Anal2002;22:547e552.

11. Herrera AG. The hazard analysis and critical control point system in food safety.Methods Mol Biol2004;268:235e280.

12. Health and Safety at Work Act 1974. London: Stationery Office. 13. (The) Management of Health and Safety at Work Regulations

1999. London: Stationery Office.

14. SHTM 2030: washer disinfectors, NHS Scotland Property and Environmental Forum 2001. Edinburgh: Stationery Office. 15. NHS Estates. HTM 2030: washer disinfectors. London:

Stationery Office; 1997.

16. NHS Estates (Scotland). Scottish Health Technical Memoran-dum 2010 (sterilizers). Edinburgh: Stationery Office. 17. Scottish Executive Health Department Working Group. The

Glennie Framework: the decontamination of surgical instru-ments and other medical devices. Report; February 2001. 18. Medical Devices Agency, Device Bulletin 2002(06). Benchtop

steam sterilizers eguidance on purchase, operation and

maintenance.

19. Scottish Government. NHS Scotland Sterile Service Provision Review Group (Glennie Framework). Report. Edinburgh: Stationery Office; 2001.

20. Medical Devices Agency. Sterilization, disinfection and cleaning of medical equipment: guidance on decontamina-tion from the Microbiology Advisory Committee to Depart-ment of Health. London: Stationery Office; 2002.

21. NHS Estates, Department of Health.A protocol for the local decontamination of surgical instruments. London: Stationery Office; 2004.

22. Anonymous.Decontamination of reusable medical devices. Part A e management and environment. HTM 01-01.

London: Department of Health, England; 2007.

23. Gordon BL, Burke FJ, Bagg J, Marlborough HS, McHugh ES. Systematic review of adherence to infection control guide-lines in dentistry.J Dent2001;29:509e516.

24. Smith AJ, Hurrell D, Bagg J, McHugh S, Mathewson H, Henry M. A method for surveying instrument decontamination proce-dures in general dental surgery.Br Dent J2007;202:E20eE23.

25. Consumer Protection Act 1998 (Product Liability). London: Stationery Office.

26. Medical devices regulations 2002. London: Stationery Office. 27. Medical Device Bulletin 2006 (04). Single-use medical

devices: implications and consequences of reuse.

28. ISO 9000:2005. Quality management systemse

fundamen-tals and vocabulary.

29. ISO 9001:2000. Quality management systemserequirements.

30. ISO 9004:2000. Quality management systems eguidelines

for performance improvements.

31. ISO 13485: 2003. Medical devices e quality management

systemserequirements for regulatory purposes.

32. PD ISO/TR 14969:2004. Medical devicesequality

manage-ment systemseguidance on the application of ISO 13485:

Figure

Figure 1 Recognition of single-use (white bars) and use-by (black bars) symbols by dental staff.

References

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