Dental hygienists serving as infection control coordinators

As health-care workers, dental team members strive daily to break the chain of infection and protect themselves and their patients. Understanding modes of disease transmission and ways to interrupt this chain is integral to developing an infection control program that protects both the patient and the practitioner. Everyone in the dental office has a responsibility for safety.

Federal and state regulations require that each dental office identify an infection control coordinator (ICC) to oversee the facility’s infection control program. The Occupational Safety and Health Administration (OSHA) requires every office have an infection control plan that addresses policies, procedures, and practices that eliminate the risk for employee exposure, whereas the Centers for Disease Control (CDC) emphasizes the need for one person to be assigned to serve as the infection control officer to oversee protection protocol for patients. As part of the dental hygiene educational process, dental hygienists are taught about pathogenesis and the infectious disease process, making them ideal candidates for ICC positions.

There are several different ways to develop an infection control plan for a dental facility. Some offices may choose to hire a consulting group to come into the office and develop a customized plan. Consulting firms can also handle initial and annual training, and they can provide phone support throughout the year. Other offices will use information from the American Dental Association (ADA), the CDC, and OSHA to develop their own plans, engaging staff in writing and implementing policies. Training is typically carried out by the dentist or licensed dental hygienist. Regardless of the avenue chosen, each office is required to appoint an ICC to provide daily support, enforcement, record keeping, and reviews.

An ICC candidate

When developing an infection control plan, a facility must identify an individual who demonstrates a willingness to take on the challenges of the position. An ideal candidate will possess a solid knowledge base of infectious disease transmission, safety precautions, and a complete understanding of the rules, laws, and recommendations of local, state, and federal agencies.

Several qualities of an ideal ICC candidate are as follows:

Someone who will embrace the position
Someone who is present and familiar with all aspects of the office
Someone who is comfortable correcting an employee if infection control has been compromised
Someone who can maintain composure in the event of a breach
Someone who possesses a high level of interest and understanding of infection control and safety

A dental hygienist or clinical assistant can fulfill the responsibilities of an ICC candidate. It is highly recommended to avoid having the dentist serve as infection control officer, due to the amount of other daily responsibilities dentists have. Dental hygienists complete a course in microbiology as part of their professional education, providing them with an understanding of bacteria and viruses, making them ideal candidates.

Developing an infection control plan

If you are approached to develop and implement an infection control plan for your dental facility and you accept the challenge, you and your employer should decide if you will tackle developing a policy in-house or if you will hire a consultant. Hiring a consultant will reduce your initial responsibility, as the consultant will provide the required logs, reports, and initial training. However, hiring a consultant can be expensive. If the decision is made to develop an infection control program in-house, there are several organizations with which you should become familiar immediately.

Understanding the differences between OSHA and the CDC will help you establish guidelines for team members versus guidelines for patients, as well as help you understand requirements versus recommendations. Notwithstanding your typical OSHA requirements for a safe work environment, OSHA provides little information for the dental and medical practice beyond the Bloodborne Pathogens (BBP) Standard, the Ionizing Radiation Policy, exit route requirements, and the Needlestick Safety and Prevention Act. OSHA also provides at no cost the required workplace safety posters. The CDC’s Guidelines for Infection Control in Dental Health-Care Settings - 2003 and Summary of Infection Prevention Practices in Dental Settings are free guides that can be very useful in developing an infection control program. The ADA recommends that all dental facilities and dental labs follow appropriate infection control procedures as identified in the CDC’s guidelines.¹ The Organization for Safety, Asepsis and Prevention (OSAP) provides infection control information for dental offices through a membership-based website.

The next step in your new role as the ICC is to understand the job. An infection control coordinator should be responsible for developing written infection prevention policies and procedures based on evidence-based guidelines, regulations, or standards.² It is the responsibility of the ICC to develop a written infection prevention policy based on the CDC guidelines, train staff, and verify that all equipment and supplies are current. As you begin gathering information, identify and analyze areas to be addressed and discuss concerns with staff members. Involve everyone—the dentist(s), assistants, and even the front desk staff. A proper policy will include sterilization procedures for instruments and materials and sterilizer monitoring.¹ Many states require specific infection control programs, so check with your state to find out what the requirements are (e.g., North Carolina requires, at minimum, one staff member to be trained in its Statewide Program for Infection Control and Epidemiology). Develop risk assessments, flow charts, logs, and checklists that address measures needed to prevent infectious disease transmission. Finally, develop compliance logs for the staff to utilize for daily and weekly compliance checklists, such as sterilization logs. Keep all forms simple. These logs may be requested in an inspection, so designate a safe place to retain these records.

When developing policy that addresses one area, such as the BBP Standard, other areas of the infection control plan will simultaneously develop. Develop and write policy that uses simple language, so it is easy to understand and recall. Policies and procedures should be tailored to the dental setting and reassessed on a regular basis (e.g., annually) or according to state or federal requirements (table 1).² Employee training is required at implementation of the policies and procedures, upon hiring a new employee prior to placing the person into a specific position, or if an employee’s job assignment changes.

The dentist/owner must recognize the role of the ICC in developing and maintaining the infection control program, and the ICC must recognize the role of the dentist as an advisor. The ICC should always be recognized as the compliance officer with the power to enforce compliance and discipline for noncompliance. Including due process will provide a description of your requirements and how noncompliance issues will be handled.

How should the ICC be compensated?

Becoming an ICC increases your responsibilities, which should be reflected with appropriate compensation. Rationale to consider when discussing compensation with your employer are initial and day-to-day responsibilities. You must always be alert that a breach in infection control could happen, which would pull you away from patient care. It is the ICC’s responsibility to verify completion of daily, weekly, and monthly checklists, as well as maintain policy manuals and oversee the annual inspections and reviews. A well-designed program with proper record keeping will protect the employer from receiving fines and penalties during an OSHA inspection. Therefore, the ICC should be compensated at a rate that is equal to an hourly production rate.

Employees who serve as infection control coordinators in large hospitals or group medical facilities report an average annual salary of $71,000, or $31.02 per hour. The salary range for ICCs is approximately $57,000 for an entry-level ICC to a high of $81,000 for a veteran employee.⁴ Serving in this role secondary to your clinical hygiene position shows a similar average pay rate to that of a dental hygienist. The median hourly salary for a dental hygienist is $33.65.⁵

Estimated time

Initially the ICC will spend 40–60 hours gathering information, meeting with staff, and developing policy. Each week, you should expect to spend no more than two hours to conduct required ICC tasks. All parties should agree on budget and time constraints prior to you assuming the position.

After implementation, the number of hours that you dedicate to safety issues will decrease. Your main role will become clerical in nature, as your tasks will be to ensure that logs are updated weekly and recorded in the infection control manual. In the event of a breach, you will be required to document the breach (e.g., a failed autoclave cycle or a sharps incident) and the corrective measures taken. A breach requires more documentation—thus, more clocked hours.

As ICC, you will oversee the annual review of the office’s OSHA and infection control policies. You can expect to spend two to four hours preparing for your meeting, which will last approximately two hours. You are always required to be available for questions.

Lori’s personal experience as infection control coordinator

As a consultant, I have personally experienced the trials and tribulations that can occur when serving in this role. One key thing that I have learned is to be transparent. One cannot expect employees to come to you with a problem or concern if they feel that you are going to blame or scold or refuse to listen to them. Provide corrections using a positive, negative, positive approach for better compliance.

While I have never had to address a major breach in infection control, one problem that I routinely address is clinical staff not wanting to wear gowns due to hot operatories. OSHA (29 CFR 1910.1030) states that all employees must wear appropriate personal protective equipment (PPE) when treating patients.³ This requires that clinical employees wear PPE that covers any exposed skin. Aerosols and splatter can be carried home on unprotected skin, putting employees’ families at risk.

How to address this issue with a staff member: Review the BBP Standard with reference to required PPE. Express your concern for the safety of your staff members and extend this concern to the safety of their families. Calmly and directly, advise the staff member in private that inadequate PPE is a breach of safety, so you are issuing a verbal warning. The staff member should be aware that if this continues he or she could be terminated for failure to comply with OSHA requirements. Conclude the encounter with sincere concern for the employee’s safety, as well as the safety of his or her family.

The next example addresses an assistant who was caught reaching into the ultrasonic with ungloved hands to retrieve instruments. This breach was twofold: a potential for a sharps incident and possible exposure to BBPs. OSHA requires that employees wear puncture-resistant gloves when handling sharp instruments. Furthermore, ultrasonic solutions typically contain glutaraldehyde, which does not provide sterilization and can cause skin irritation.

How to address this issue with a staff member: Start by reviewing the office policy that addresses handling sharps. Discuss the increased chance for a puncture wound without appropriate PPE. A puncture wound from a dirty or contaminated instrument would require multiple medical tests for both the employee and any patient treated that day. Document and advise the employee of the breach in the employment record. Warn that subsequent failures to follow protocol can lead to termination. Be courteous yet firm, and express concern.

A final example of an infection control breach that should be addressed by the ICC involves a situation that could lead to multiple patients being exposed to infectious pathogens. When studying modes of transportation of pathogens, we learn that any object in the operatory becomes a source for transmission if it is not properly disinfected. Often a dental office can become busy, requiring staff to turn operatories quickly, which leads to shortcuts in infection control. When applying disinfectant to environmental surfaces and equipment, it is critical that it remain on the surface long enough to kill pathogens, as recommended by the disinfectant solution’s instructions. Recently, when performing a walk-through prior to conducting a training session in an office for which I consult, I witnessed an employee spray Cavicide on a patient chair. After immediately drying it with a paper towel, she seated the next patient. This is not acceptable, as the proper kill time had not been respected.

How to address this issue with a staff member: Review with the staff member the protocol for disinfection and the need to break the chain of infection for both ourselves and our patients. Address the staff member without appearing accusatory. Discover why the staff member is rushing through infection control steps, then kindly express concern that the policy for disinfection is not being followed, putting the office at risk. Just as we try to get our patients to “own” their diagnosis for compliance, if we “own” our infection control protocols, we as employees tend to comply.

Conclusion

Serving in the capacity of ICC can be rewarding for a dental hygienist. You will utilize your clinical skills and your knowledge of disease processes to break the chain of infection to protect yourself, your fellow employees, and your patients. Before you take the leap beyond the operatory to become an infection control coordinator, review your knowledge of the pathogenesis of infectious diseases, and familiarize yourself with organizations such as OSHA, the CDC, and OSAP.

References
1.   Department of Scientific Information, ADA Science Institute. Infection Control and Sterilization. American Dental Association website. https://www.ada.org/en/member-center/oral-health-topics/infection-control-resources. Updated October 22, 2018. Accessed June 5, 2019.
2.   Centers for Disease Control. Summary of Infection Prevention Practice in Dental Settings: Basic Expectations for Safe Care. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; October 2016. https://www.cdc.gov/oralhealth/infectioncontrol/pdf/safe-care2.pdf. Accessed June 6, 2019.
3.   Occupational Safety and Health Administration. Medical & Dental Offices: A Guide to Compliance with OSHA Standards. Washington, DC: Occupational Safety and Health Administration, United States Department of Labor; 2003. https://www.osha.gov/Publications/OSHA3187/osha3187.html. Accessed June 6, 2019.
4.   Average Infection Control Coordinator Salary. Payscale website. https://www.payscale.com/research/US/Job=Infection_Control_Coordinator/Salary. Accessed June 10, 2019.
5.   Average Dental Hygienist Hourly Salary. Payscale website. https://www.payscale.com/research/US/Job=Dental_Hygienist/Hourly_Rate. Accessed June 10, 2019.

LORI GORDON HENDRICK, BSDH, RDH, CDT, is a dental office infection control consultant. She practices clinical hygiene and functions as office manager in a busy private practice in North Carolina. She also owns and operates Athena Dental Solutions LLC, a dental lab and consulting business. She has personal experience in developing and training dental office staff in OSHA, infection control, and HIPAA. Throughout her career in dentistry, she has experienced two OSHA inspections without any fines or penalties. She may be reached at [email protected].

JOSEPH R. HENDRICK JR., DDS, is a licensed dentist with more than 35 years of experience in providing clinical dental care. He is active in organized dentistry in North Carolina as a past president of his local dental society, and as a current board of trustee member of the North Carolina Dental Society. He enjoys sharing his knowledge of dentistry with new dentists and hygienists and serving as a mentor to new graduates. He may be reached at [email protected] or josephrhendrickjr.com.