Management of infection control in dental practice

Transcription

1 Journal of Hospital Infection (2009) 71, 353e358 Available online at 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 b Biostatistics & 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 policies and procedures associated with infection control and instrument decontamination 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 control 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 majority of surgeries have policies and procedures for the management of infection 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. ª 2009 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.: þ ; fax: þ address: a.smith@dental.gla.ac.uk /$ - see front matter ª 2009 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi: /j.jhin

2 354 A. Smith et al. Introduction Infection prevention and control are key elements in providing a safe environment for patients and staff within a dental practice. 1e5 Recent media interest and publications have created heightened concern. 6 The discovery of vcjd and the potential for spread of not only this agent, but also bloodborne viruses and other infectious agents, via inadequately 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 appropriately risk-assessed environment. 1,2,8e11 The British Dental Association (BDA) Advice Sheet A12 on infection control in dentistry provides broad advice on the roles and responsibilities 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 procedures routinely, have been appropriately trained and have demonstrated competence in particular procedures. This must be documented. There are also technical standards for Local Decontamination 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 activities. 9,12e23 A job description should set out these responsibilities to manage infection control in accordance 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 acquisition and disposal). The surgery should have written policies and procedures that define, document 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. 23 In order to address these shortcomings, 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 practices that were visited between January 2003 and March 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 (N ¼ 837). This list was the basis for randomly selecting practitioners to survey. A two-stage proportional stratified random sampling method was used to identify which surgeries were to be surveyed. First, practices were randomly 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

3 Infection control in dental practice 355 reading. 24 The survey visits ran from January 2003 until the end of March Technical requirements and guidance The data collection forms for the survey were based on a number of technical requirements and guidelines. 1,12e20 In addition, data were collected to examine compliance with a number of legal requirements 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 Management of Health and Safety at Work Regulations ,13,25,26 Results Data were available from 179 surgeries for analysis. 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 practitioners, 38% of dental hygienists and 2% of ancillary staff undertook decontamination of instruments. In no surgery were dental technicians undertaking decontamination of instruments. Infection control management and decontamination 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 available within the practice, only 50% were documented. 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). Although 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 commercially 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 surgeries. 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-bystep 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 decisions taken. Staff training The ability of staff to recognise safety symbols on medical devices is good practice. 27 The knowledge of dental staff in the recognition of common symbols is summarised in Figure 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 Qualification (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.

4 356 A. Smith et al Dental nurse 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 decontamination. 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 Dentist Figure 1 Recognition of single-use (white bars) and use-by (black bars) symbols by dental staff. In 93% of surgeries there was a waste disposal policy, of which 53% were documented. Punctureproof containers were used for the disposal of sharps in 99% of surgeries, all of which were compliant with BS7320. Partly used local anaesthetic 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%) decontaminated 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 equipment. 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 dental 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 Hazardous 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 microbiological 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

5 Infection control in dental practice 357 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 documented availability of these papers. Many surgeries had access to, and used, the BDA Advice Sheet A12 which, although providing broad principles, is insufficiently detailed to provide procedures and work instructions for many aspects of infection control and decontamination of instruments. This is highlighted by the lack of knowledge of the dental team on interpretation of the single use symbol on medical device packaging. The deficiencies in the management of infection control were also highlighted by the lack of specific infection 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 segregation and disposal of clinical waste. The range of methods for disposal of partly discharged anaesthetic 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 traceability 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 reassurance 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 identified in this study could be rectified by the application 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 dental 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 documentation 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 approach. 10,11 This system has been adapted for use in other small professional and industrial environments, such as food premises, together with a system of independent inspection. Application of the HACCP system is also compatible with the implementation 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 appropriate quality management system in dental practice if long-term investments and improvements 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; Centers for Disease Control and Prevention. Guidelines for infection control in dental health care settings. Morb Mortal Weekly Rep 2003;52:RR Bentley EM, Sarll DW. Improvements in cross infection control in general dental practice. Br Dent J 1995;179:19e Bagg J, Sweeney CP, Roy KM, Sharp T, Smith A. Cross infection control measures and the treatment of patients at risk of Creutzfeldt Jakob disease in UK general dental practice. Br Dent J 2001;191:87e Scottish Executive Health Department, Healthcare Associated Infection Task Force. The NHS Scotland code of practice for the local management of hygiene and healthcare associated infection. St Andrew s House, Edinburgh: SEHD; Roy KM, Ahmed S, Cameron SO, Shaw L, Yirrell D, Goldberg D. Patient notification exercise following a dentist s admission of the periodic use of unsterilized instruments. J Hosp Infect 2005;60:163e Department of Health, England. Getting ahead of the curve: a strategy for combating infectious diseases. London: Department of Health; 2002.

6 358 A. Smith et al. 8. Pellowe CM, Pratt RJ, Harper P, et al. Evidence based guidelines 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; Hulebak KL, Schlosser W. Hazard analysis and critical control point (HACCP) history and conceptual overview. Risk Anal 2002;22:547e Herrera AG. The hazard analysis and critical control point system in food safety. Methods Mol Biol 2004;268:235e Health and Safety at Work Act London: Stationery Office. 13. (The) Management of Health and Safety at Work Regulations London: Stationery Office. 14. SHTM 2030: washer disinfectors, NHS Scotland Property and Environmental Forum Edinburgh: Stationery Office. 15. NHS Estates. HTM 2030: washer disinfectors. London: Stationery Office; NHS Estates (Scotland). Scottish Health Technical Memorandum 2010 (sterilizers). Edinburgh: Stationery Office. 17. Scottish Executive Health Department Working Group. The Glennie Framework: the decontamination of surgical instruments and other medical devices. Report; February Medical Devices Agency, Device Bulletin 2002(06). Benchtop steam sterilizers e guidance on purchase, operation and maintenance. 19. Scottish Government. NHS Scotland Sterile Service Provision Review Group (Glennie Framework). Report. Edinburgh: Stationery Office; Medical Devices Agency. Sterilization, disinfection and cleaning of medical equipment: guidance on decontamination from the Microbiology Advisory Committee to Department of Health. London: Stationery Office; NHS Estates, Department of Health. A protocol for the local decontamination of surgical instruments. London: Stationery Office; Anonymous. Decontamination of reusable medical devices. Part A e management and environment. HTM London: Department of Health, England; Gordon BL, Burke FJ, Bagg J, Marlborough HS, McHugh ES. Systematic review of adherence to infection control guidelines in dentistry. J Dent 2001;29:509e Smith AJ, Hurrell D, Bagg J, McHugh S, Mathewson H, Henry M. A method for surveying instrument decontamination procedures in general dental surgery. Br Dent J 2007;202:E20eE Consumer Protection Act 1998 (Product Liability). London: Stationery Office. 26. Medical devices regulations London: Stationery Office. 27. Medical Device Bulletin 2006 (04). Single-use medical devices: implications and consequences of reuse. 28. ISO 9000:2005. Quality management systems e fundamentals and vocabulary. 29. ISO 9001:2000. Quality management systems e requirements. 30. ISO 9004:2000. Quality management systems e guidelines for performance improvements. 31. ISO 13485: Medical devices e quality management systems e requirements for regulatory purposes. 32. PD ISO/TR 14969:2004. Medical devices e quality management systems e guidance on the application of ISO 13485: 2003.