Whose job is this anyway?

March 1, 2006
While the entire team should develop an infection control plan, each individual in the practice needs to be responsible for implementing it.

While the entire team should develop an infection control plan, each individual in the practice needs to be responsible for implementing it.

By Elizabeth Hughes, RDH, MS, and R. Hunter Rackley, Jr., RDH, BSDH, MHE

The entire dental team should be involved in developing a total office infection control plan. However, for issues as critical as infection control, a specific person should be responsible for implementing and sustaining a comprehensive infection control policy, and this could logically be the dental hygienist.

Dental health-care workers are constantly at risk for exposure to bloodborne pathogens and infectious agents from their work environment. Infection control refers to a comprehensive program that prevents the transmission of infectious agents among persons in the work environment. The goal of infection control is to eliminate the potential for disease transmission from clinician to patient, patient to clinician, or patient to patient. Each dental practice must establish, implement and maintain an infection control program that includes procedures, management of hazardous materials, compliance guidelines, protocol for exposure incidents, and efficient execution and methods to control cost. Even though the ultimate responsibility belongs to the employer dentist, this task can be comfortably delegated to the dental hygienist.

Hygienists graduate prepared to assume the responsibility of infection control, and this should be part of the hygienist’s job description in a private practice. Biomedical sciences, including microbiology, the foundational discipline for understanding disease and disease transmission, must be included in all dental hygiene curriculums. This requirement ensures that dental hygienists have a basic understanding of microbiology, the disease process and the modes of disease transmission. Dental hygiene students must also show competence in infection control techniques and procedures, not just control procedures of the physical environment but also sterilization of instruments and personal protection.

Ideally, time to maintain and implement an infection control program should be allotted into the workweek. After a systematic infection control program is implemented, time away from direct patient care to maintain the program is minimal. The dental office that values patient and clinician safety will find this slight disruption in schedule a necessary part of doing business.

New safety products and equipment appear continually and advances in research bring new approaches to controlling the spread of disease. New and revised state, local and federal regulations require constant diligence to remain current. Continuing education is a requirement for re-licensure for the dental hygienist. This is a prescribed opportunity to keep up with ever-changing regulations, as well as new scientific evidence that might change office protocols. The trend toward evidence-based education and practice prepares the hygienist to evaluate chemical labels, scrutinize manufacturer’s claims and interpret clinical data. The hygienist can find the most efficacious products to reach the desired safety outcomes. Accordingly, dental hygienists have the knowledge to discern reasonable care from unnecessary and expensive infection control overkill.

A written protocol of procedures is the first step toward assuring knowledge and compliance of infection control procedures. This allows all office personnel to review the material, gain a basic understanding of the program goals, and appreciate their roles as safety agents. Guidelines and regulations developed by the Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA) have established national standards for infection control.

The infection control coordinator should ensure that new and current team members are up-to-date on their immunizations. Vaccines recommended for all health-care workers include hepatitis B, influenza, measles, mumps, rubella and varicella. Pneumococcal vaccine is recommended for health-care workers due to their increased exposure.

The coordinator should help employees become aware of the numerous routes through which pathogens can be transferred, and each person’s role in breaking this chain. Office personnel should know the roles of personal protective equipment such as outer attire, gloves, glasses and masks, the steps for disinfection of the operatory before and after patient treatment, barriers and their roles in reducing cross contamination, proper handling of contaminated instruments and preparation for sterilization, and use of disposable items in infection control.

The infection control coordinator should be aware of the work restrictions recommended by the U.S. Public Health Service for health-care workers with certain infections or exposure to some diseases. Many of these infections are preventable with vaccines. An example of a restriction would include workers with mumps or measles. Dental office personnel should not work during the acute illness phase, nor after exposure and during the incubation phase if not immunized. If a worker is suffering from an upper respiratory infection, he or she should avoid contact with high-risk, medically compromised patients. Dental health-care workers with hepatitis A should not have direct patient contact. A special set of precautions is in place for dental personnel with hepatitis B. The CDC recommends that e-antigen positive individuals consult with an expert review panel to determine what precautions they should take to safely treat patients. The e-antigen is associated with a higher risk of transmission from health-care provider to patient in spite of universal precautions.

Work practice controls may change the way a procedure is performed and attempt to eliminate the infection hazard. All dental team members should consider the potential for hazard in the work environment. The team should attempt to reduce exposure to sharps, use high-speed evacuators to reduce aerosol contamination, use pre-procedural rinses to reduce the bacterial load in aerosols, and use an ultrasonic cleaner to decontaminate used instruments prior to sterilization.

A system of spore testing or biological monitoring should be in place to verify that the office sterilization procedures are effective for killing highly resistant bacterial spore. Other risk reduction protocols include monitoring the use of personal protective clothing such as footwear, eye protection and masks.

Primary prevention involves all efforts to avoid injury during each phase of dental services. The hygienist and other team members should assess the risk in these areas and determine the necessary actions to eliminate or reduce the risk. The ultimate goal is to prevent an exposure to patient, office worker or clinician. In dental office infection control strategies, an ounce of prevention is worth a pound of cure. Sound safety practices take considerably less time than dealing with the consequences of exposure, not to mention the comfort of knowing that you have a good system of infection control policies monitored by a knowledgeable, licensed health care professional.

Editor’s Note: References available upon request.

Elizabeth Hughes, RDH, MS is Assistant Professor in the Department of Periodontics and Allied Dental at the Indiana University School of Dentistry in Indianapolis where she is clinic and course director for the second-year dental hygiene students. R. Hunter Rackley, Jr., RDH, BSDH, MHE is Assistant Professor in the Department of Periodontics and Allied Dental at the Indiana University School of Dentistry in Indianapolis where he is preclinical and clinical course director for the first-year dental hygiene students.

Makin’ a list and checkin’ it twice...

Drs. Chris Miller and Charles Palenik have identified the following duties for managing an infection control program in a dental practice:

  • Continually review infection control, hazardous materials and other office safety regulations
  • Prepare, review and update the office exposure control plan, infection control procedures manual, hazard communication program and other safety procedures
  • Develop protocols to be followed in practicing office infection control
  • Provide new and continuing team members with initial and updated training on all policies and procedures
  • Assure that the janitorial staff has received proper training related to personal protection during office cleaning procedures
  • Monitor compliance with office safety procedures and related regulations
  • Organize and manage procedures for hepatitis B vaccinations of new team members, as well as personal vaccination histories and procedures for post-exposure medical evaluations and follow-up
  • Review circumstances surrounding exposure incidents
  • Select, evaluate and maintain the stock of products and equipment needed to accomplish office safety
  • Assure proper maintenance, availability, cleaning and disposal of personal protective equipment and all other items needed for office safety
  • Perform spore-testing of office sterilizers at recommended intervals
  • Manage disposal of relegated medical waste
  • Check equipment for decontamination and label any contaminated portions before shipping for repair
  • Organize and maintain material safety date sheets, proper labeling, the inventory list and proper storage for all hazardous chemicals in the office
  • Maintain appropriate documents and records
  • Assure that all members of the dental team have opportunities to voice concerns about and suggest improvements in the office infection control program
  • Communicate with patients regarding infection procedures practiced in the office