Our fellow hygienists have spoken. Not just a few of them, but hundreds. A survey from November 2019 to March 2020 asked 770 hygienists about infection control (IC) practices in their clinics. The results clearly show that our profession has an opportunity for growth in this area. We explore three main findings and their significance in today’s dental world.
1. 47% of dental hygienists wish that infection control procedures in their office would improve
About 53% of survey respondents thought that there was a good IC system in place at their clinics, which was encouraging to hear. However, this still means that almost one in every two dental practices might not be up to standard.
Although a 100% outcome might not be practically possible, there is certainly room for improvement. However, for an effective IC program, there should be someone responsible for leading the charge.1
The Centers for Disease Control and Prevention (CDC) provides a recommended solution: an infection control coordinator (ICC)—someone accountable for a feasible and sustainable infection prevention program that is dedicated to championing health-care safety.2 Let’s look at some factors to consider when implementing this.
Who should be your ICC: Your ICC, at minimum, needs to understand infection prevention, basic safety processes, methods to avoid cross-contamination, and knowledge of equipment and products available in the market to ensure staff and client safety.
If you have no excess capacity, are unsure how to set up a sustainable IC system, or prefer an expert’s objective viewpoint of your clinic’s practices, consider engaging an IC consultant. Should you be confident in the in-house route, you can start by hiring a fully-dedicated ICC or identifying existing suitable staff and assigning them this task.3
Role of the ICC: The overarching duty of the ICC is to develop infection prevention policies and processes based on industry legislation, guidance, and best practices.2 The ICC should be the go-to person for the rest of the employees, conducting regular IC training as needed. The aim is to keep the practice updated on the most recent regulatory recommendations and requirements, and sharing information on new dental products, equipment, chemicals, and technologies.4
With over 30 years of experience, Kim Laudenslager, a Colorado RDH and an OSHA trainer, views employee training as one of the most misunderstood health-care safety areas.5,6 Among other things, she believes in conducting training live and with interactive case studies, fully financed by employers, and scheduled during the workday. All staff, even temporary or part-time, should be equipped to deal with any IC issues that are part of their job scope. That way, there will be no chance for pathogens to cause trouble in the office.
ICCs are also accountable for maintaining the availability of well-fitting personal protective equipment for all employees in the dental work environment.7 Lastly, ICCs should also consistently ensure that the team has undergone any required immunizations as they are critical to infection prevention. Immunizations recommended by the CDC include the hepatitis B, hepatitis C, and human immunodeficiency virus vaccinations.2
Support for the ICC: To be sufficiently equipped for their numerous responsibilities, the ICC needs consistent support. Besides educating, implementing, and monitoring the clinic’s IC program, the ICC must be allowed enough time and financial resources to access continuing education such as professional publications, subject-specific courses and conferences, and IC-related memberships.4 For more information on industry standards and guidance, visit the CDC website.7
An infectious outbreak can have devastating effects on a clinic’s reputation and long-term viability. Whichever approach is decided, having an ICC is one of the best ways to prevent this from happening.
2. 43% of dental hygienists don’t have enough time after each appointment to complete infection control procedures
The unfortunate result: 36% of participants only had time for IC activities after some appointments, and 7% didn’t have any time for IC work at all. Proper cleaning, disinfecting, and sterilizing take time, and Ethel Hagans, RDH, lamented the lack of time during a previous work experience to complete basic IC tasks such as cleaning the operatory.8
Many hygienists don’t work with assistants, so they often have to set aside appointment time for IC activities. In the absence of adequate infection prevention, pathogens can be transmitted among patients, the team, the dentist, and their families. We all must play our roles in breaking the chains of infection.
To do this, appointment schedules must take into consideration preparation, treatment, consultation, documentation, and operatory reprocessing time. Also, although IC processes for each clinic will vary depending on differences such as products and equipment used, the following are some best practices we can all adopt.
Disinfection and sterilization:7 All items coming in contact with patients must be properly cleaned and then reprocessed (i.e., disinfected or sterilized). To do so, ensure that manufacturer guidelines for reprocessing are readily accessible, preferably at or near the reprocessing spot. (Do note that some objects only require one-step cleaning and disinfecting, while others have multiple steps.)
Put on suitable protective equipment throughout this process. If you have insufficient time to process all items in between appointments, place used instruments into a holding solution for a presoak before fully processing them later.9
When disinfecting, check how long the disinfectant needs to stay wet on the surface. If you don’t have the time to let the surface stay wet for the appropriate time, you are not adequately disinfecting between patients.10 Moreover, for sterilization, many clinicians do not know that all packaged instruments should be labeled with the sterilizer used, load/cycle number, date of sterilization, and expiration. This IC procedure may be time-consuming, but it will be helpful if the sterilizer does not pass a biological spore test and instruments that were possibly not sterilized need to be identified.
Environmental infection control:7 Environmental surfaces don’t come into direct contact with patients’ mucous membranes, but contamination can occur through touch, liquid splashes, or droplets produced throughout patient care.
These surfaces fall into two categories: housekeeping surfaces and clinical contact surfaces. Housekeeping surfaces such as walls and floors have a lower probability of being affected. However, clinical contact surfaces such as trays, switches, and light handles are highly likely to be contaminated from spatter or dental personnel’s gloves, warranting a greater focus for cleaning and disinfection.
One way of reducing contamination, especially for clinical contact surfaces, is by using barrier wraps, especially for items that are more difficult to clean—computer equipment, switches on dental chairs, and other electronics. By wrapping up these surfaces, staff can simply change the barriers between clients to prevent contamination.
Water-line safety:7 Contaminants such as microbes can grow up to 200,000 colony-forming units per milliliter of water within less than five days in newly installed tubing and can lead to infections among your patients through your water lines. Hence, offices must ensure that water flowing through their tubing is filtered and treated to meet potable water standards. The CDC advises flushing water lines for at least 20-30 seconds after each client to prevent patient material from seeping into the tubing. Dental units using independent water reservoirs can also purge their water lines each night and whenever units are not in use.
It is best practice to monitor water quality through consistent testing. Each time you receive results, check in with your dental unit manufacturer to ascertain the most appropriate maintenance or treatment protocol.
Overall best practices: Generally, it is sound practice to reduce clutter in the workspace as much as possible. Having fewer items reduces the number of objects that can be contaminated. Also, having a standard procedure or routine for the entire team to follow, such as the CDC checklists, can help everyone become familiar with the new IC system sooner.7
Ultimately, though, everyone in the office needs to feel responsible for and dedicated to improving IC levels. Having an ICC on the team can provide much-needed leadership, but change only becomes sustainable with the whole team’s commitment, which brings us to our next finding.
3. 52% of dental hygienists find that not everyone on their team adapts quickly to new recommendations on infection control
This statistic raises significant concern, particularly during emergency situations such as the current COVID-19 global crisis. No matter how much we try to socially distance ourselves, the nature of dental work requires both dental personnel and patients to come into close proximity.
Although the current outbreak will pass, we as professionals have a duty to do no harm, and that includes quickly incorporating new IC information and protocols into our practice to prevent the chain of infection as much as possible. If the team struggles to adapt when new information emerges, consider tackling one of two obstacles that may be holding them back.
Lack of awareness of IC importance and updates: From his extensive experience as an infection control and compliance officer, Duane Tinker shares the most prevalent and dangerous issue he comes across—complacency.11 Many of his clients didn’t wear protective equipment appropriately, citing reasons such as their hardy immune system, how saliva isn’t a big deal, how they don’t like putting on the equipment, and how they will wear it if their patients look sick. However, these explanations aren’t backed by science at all. Continual IC education is of utmost importance. Knowing how busy hygienists can be, why not introduce the CDC DentalCheck app in your practice?12 This app makes it easy to see if your procedures are meeting standards.
Fear of the uncertainty change brings: Our minds are used to associating familiar circumstances with safety because we know from experience that we can cope with these situations. The opposite, then, can also be true—unfamiliar things seem scary; we don’t yet know what they mean for our loved ones and us. When employees learn of organizational changes, especially large-scale ones, the natural thought is: “Will I still have a job after this?”
If the dentist is planning something massive such as an IC program overhaul, the number one priority should be to assure the staff that their positions remain secure.13 Once they feel sure about their future with the practice, they will be more likely to welcome changes enthusiastically. Next, enact change at a comfortable pace.14 Listen to their struggles and praise their efforts often. Change is tricky for most people, and every little gesture can go a long way in assuring people.2
Employers can help their employees get over their fear of the unknown by actively involving them in the change process. When employers are willing to incorporate helpful suggestions from the team, the action plan will be implemented more seamlessly.13 The team will be more comfortable during this transformation if they know their opinions are heard.
If some team members are slower adapters to change, consider bringing them on the planning team early.14 Once they buy into things, the sense of ownership they get from contributing to these changes will make for a faster rollout in the long run.
In light of the intimate nature of dental hygiene work, and especially during the current COVID-19 mass outbreak, we really must step up our infection control game. What may previously have been mechanical procedures are now an absolute necessity. Let’s be careful now so that we can all be safe later!
References
1. Occupational Safety & Health Administration. Hazard communication guidelines for compliance. 2000. https://www.osha.gov/Publications/osha3111.html. Accessed Mar. 25, 2020.
2. Centers for Disease Control and Prevention. Guidelines for infection control in dental health-care settings—2003. Dec. 19, 2003. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm. Accessed Mar. 25, 2020.
3. Occupational Safety & Health Administration. Bloodborne pathogens. https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030. Accessed Mar. 25, 2020.
4. Organization for Safety, Asepsis and Prevention. The role of the ICPC. https://www.osap.org/page/RoleofICPC. Accessed Mar. 25, 2020.
5. About Kim. Kim Laudenslager website. https://kimlaudenslager.com/about-kim/. Accessed 25 Mar. 2020.
6. Creehan K. Keeping members safe since 1990. J Colorado Dent Assoc. Winter 2020. https://cdaonline.org/news/latest-news/keeping-members-safe-since-1990/. Accessed Mar. 25, 2020.
7. Centers for Disease Control and Prevention. Summary of infection prevention practices in dental settings: Basic expectations for safe care. 2016;Oct. https://www.cdc.gov/oralhealth/infectioncontrol/pdf/safe-care2.pdf. Accessed Mar. 25, 2020.
8. Hagans E. A hygienist says: Stop cutting into my hygiene time! Mod Hygienist. 2017;Jun. https://www.dentalproductsreport.com/hygiene/article/hygienist-says-stop-cutting-my-hygiene-time. Accessed Mar. 25, 2020.
9. Kelsch N. Letting dirty dishes wait: Enzymatic presoaks ‘delay’ sterilization process for more important tasks. RDH. 2017;Jan.16. https://www.rdhmag.com/infection-control/sterilization/article/16409901/letting-dirty-dishes-wait-enzymatic-presoaks-delay-sterilization-process-for-more-important-tasks. Accessed Mar. 25, 2020.
10. Pine P. Dissecting your disinfectant. RDH. 2013;Aug. https://www.rdhmag.com/career-profession/article/16406583/dissecting-your-disinfectant. Accessed Mar. 25, 2020.
11. Dental Compliance Specialists website. https://dentalcompliance.com/about/. Accessed Mar. 25, 2020.
12. Centers for Disease Control and Prevention. CDC DentalCheck Mobile App. https://www.cdc.gov/oralhealth/infectioncontrol/dentalcheck.html. Accessed Mar. 25, 2020.
13. Reddy K. 10 best ways to help employees adapt to change quickly. Apr. 9, 2020. https://content.wisestep.com/employees-adapt-to-change/. Accessed Mar. 25, 2020.
14. Forbes Coaches Council. 10 ways managers can help employees adjust to change. Dec. 21, 2016. https://www.forbes.com/sites/forbescoachescouncil/2016/12/21/10-ways-managers-can-help-employees-adjust-to-change/. Accessed Mar. 25, 2020.
Michelle Strange, MSDH, RDH, brings 19 years of experience in dentistry to her roles as adjunct clinical faculty member at Trident Technical College, clinical educator for TePe Oral Health Care, director of education for O2 Nose Filters, and host of the “A Tale of Two Hygienists” podcast. In 2019, she started a company with Dr. Tony Stefanou called TriviaDent to test your dental knowledge, network, and win prizes. You can reach out to Michelle via her podcast ataleoftwohygienists.com.
