Assessing Your Dental Services for Compliance

First in a series on Regulatory Compliance for Dental Services!

When performing dental services, you first need to identify the types of procedures that will be performed in the organization or office. This includes the type of anesthesia that will be offered to the patients as well as the type of equipment needed to perform the services offered. But first, the basics need to be addressed. This article will discuss Administrative Responsibilities, Education and Training, Personnel Safety, Program Evaluation, Hand Hygiene, Personal Protective Equipment, Respiratory Hygiene/Cough Etiquette, Sharp Safety, Safe Injection Practices, Sterilization and Disinfection of Patient Care Devices, and Environmental Infection Prevention and Control. So, here we go.

Administrative

The organization/office needs to develop and maintain infection prevention and occupational health programs for dental services. There needs to be supplies necessary for adherence to Standard Precautions such as hand hygiene products, safer devices to reduce percutaneous injuries, and personal protective equipment. The organization/office needs to develop and maintain written infection prevention policies and procedures appropriate for the services provided by the facility and based on evidence-based guidelines, regulations, or standards. The facility needs to have a system for early detection and management of potentially infectious persons at the initial points of the patient encounters. Finally, tracking and trending of any infections and actions taken to prevent reoccurrence.

Education and Training     

Education and training are an important and necessary part of providing dental services. There needs to be job- or task-specific infection prevention education and training for all dental health care personnel (DHCP). This includes training on principles of both DHCP safety and patient safety, training during orientation and at regular intervals (e.g., annually), and maintaining training records according to state and federal requirements.

Personnel Safety

Facilities need to consider the current CDC recommendations for immunizations, evaluation, and follow-up. There needs to be a written policy regarding immunizing DHCP, including a list of all required and recommended immunizations for DHCP (e.g., hepatitis B, MMR (measles, mumps, and rubella) varicella (chickenpox), Tdap (tetanus, diphtheria, pertussis). All DHCP should be screened for tuberculosis (TB) upon hire regardless of the risk classification of the setting. There need to be referral arrangements in place to qualified health care professionals (e.g., occupational health program of a hospital, educational institutions, health care facilities that offer personnel health services) to ensure prompt and appropriate provision of preventive services, occupationally related medical services, and postexposure management with medical follow-up if required. The facility should have well-defined policies concerning contact of personnel with patients when personnel have potentially transmissible conditions.

Program Evaluation

The organization should perform routine evaluations of the infection prevention program, including evaluation of DHCP adherence to infection prevention practices.

Hand hygiene

All DHCP must perform hand hygiene properly. This needs to happen -

• When hands are visibly soiled.
• After touching instruments, equipment, materials, and other objects which are likely to be contaminated by blood, saliva, or respiratory secretions.
• Before and after treating each patient.
• Before putting on gloves and again immediately after removing gloves.

Use soap and water when hands are visibly soiled (e.g., blood, body fluids); otherwise, an alcohol-based hand rub may be used.

Personal Protective Equipment (PPE)

Facilities need to provide sufficient and appropriate PPE and ensure it is accessible to DHCP and educate all DHCP on the proper selection and use of PPE. DHCP should wear gloves whenever there is potential for contact with blood, body fluids, mucous membranes, non-intact skin, or contaminated equipment.

• Do not wear the same pair of gloves for the care of more than one patient.
• Do not wash gloves. Gloves cannot be reused.
• Perform hand hygiene immediately after removing gloves.

DHCP need to wear protective clothing that covers skin and personal clothing during procedures or activities where contact with blood, saliva, or other potentially infectious materials are anticipated, and mouth, nose, and eye protection during procedures that are likely to generate splashes or spattering of blood or other body fluids. Remove PPE before leaving the work area.

Respiratory Hygiene/Cough Etiquette

All efforts need to be made to contain respiratory secretions in patients and accompanying individuals who have signs and symptoms of a respiratory infection, beginning at the point of entry to the facility and continuing throughout the visit. This can be accomplished by:

Posting signs at entrances with instructions to patients with symptoms of respiratory infection to:

• Cover their mouths/noses when coughing or sneezing.
• Use and dispose of tissues.
• Perform hand hygiene after hands have been in contact with respiratory secretions.
• Provide tissues and no-touch receptacles for disposal of tissues.
• Provide resources for performing hand hygiene in or near waiting areas.
• Offer masks to coughing patients and other symptomatic persons when they enter the dental setting.

Providing space and encouraging people with symptoms of respiratory infections to sit as far away from others as possible. If available, facilities may wish to place these patients in a separate area while waiting for care.

It is also important to educate DHCP on the importance of infection prevention measures to contain respiratory secretions to prevent the spread of respiratory pathogens when examining and caring for patients with signs and symptoms of a respiratory infection.

Sharps Safety

Another key area to be aware of is sharps safety. It is important to adopt the following guidelines to avoid unnecessary injury/needlesticks.

• Consider sharp items (e.g., needles, scalers, burs, lab knives, and wires) that are contaminated with patient blood and saliva as potentially infective and establish engineering controls and work practices to prevent injuries.
• Do not recap used needles by using both hands and any other technique that involves directing the point of a needle toward any part of the body.
• Use either a one-handed scoop technique or a mechanical device designed for holding the needle cap when recapping needles (e.g., between multiple injections and before removing from a non-disposable aspirating syringe).
• Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers located as close as possible to the area where the items are used. When full, replace these containers and have them disposed of properly.

Safe Injection Practices

Another important part of managing medications is making sure that injections are administered safely and within the guidelines of infection control. To prevent medication contamination and the potential for medication-related adverse events the following practices need to be employed and monitored:

• Prepare injections using aseptic technique in a dedicated, clean, clutter-free area.
• Disinfect the rubber septum on a medication vial with alcohol before piercing.
• Do not use needles or syringes for more than one patient (this includes manufactured prefilled syringes and other devices).
• Medication containers (single and multidose vials, ampules, and bags) are entered with a new needle and new syringe, even when obtaining additional doses for the same patient.
• Use single-dose vials for parenteral medications when possible.
• Do not use single-dose (single-use) medication vials, ampules, and bags or bottles of intravenous solution for more than one patient.
• Do not combine the leftover contents of single-use vials for later use.
• The following apply if multidose vials are used:
  • Dedicate multidose vials to a single patient whenever possible.
  • If multidose vials are used for more than one patient, they should be restricted to a dedicated medication area and should not enter the immediate patient treatment area (e.g., dental operatory) to prevent inadvertent contamination.
  • If a multidose vial enters the immediate patient treatment area, it should be dedicated for single-patient use and discarded immediately after use.
  • Date multidose vials when first opened and discard within 28 days unless the manufacturer specifies a shorter or longer date for that opened vial.
• Do not use fluid infusion or administration sets (e.g., IV bags, tubing, connections) for more than one patient.

Sterilization and Disinfection of Patient Care Devices

One area that is a major concern and one that is high on the regulatory agency survey teams’ radar is high-level disinfection/sterilization. This area is one that can cause facilities grief if strict adherence to the processes is not followed. HLD non-compliance can lead to CONDITIONAL accreditation. Here are some tips for complying with the regulatory standards.

• Clean and reprocess (disinfect or sterilize) reusable dental equipment appropriately before use on another patient. Single-use items are to be discarded in a sharps container or per the organization’s policy and procedure.
• Clean and reprocess reusable dental equipment according to Manufacturer Instructions for Use. If the manufacturer does not provide such instructions, the device may not be suitable for multi-patient use.
• Have Manufacturer Instructions for Use for reprocessing reusable dental instruments/equipment readily available, ideally in or near the reprocessing area. These need to be updated periodically as manufacturers may change their reprocessing instructions.
• Assign responsibilities for reprocessing dental equipment to DHCP with appropriate training. Competencies should be completed prior to the DHCP performing reprocessing.
• Wear appropriate PPE when handling and reprocessing contaminated patient equipment.
• Ensure that there is a leak-proof, puncture-proof container with a biohazard sticker on it, in the procedure room for transfer of dirty instrumentation to the reprocessing area to avoid staff injury.
• Perform hand hygiene.
• Don PPE as required per Manufacturer’s Instructions for Use for the cleaning agent being used.
• Rinse/wipe the instruments with water, to remove any visible blood, bioburden, etc.
• Place the instrument into the leak proof, puncture proof container.
• Ensure that all the instruments are in the open position so that enzymatic gets into all parts of the instrument.
• Spray the instruments with Enzymatic.
• Secure the container lid.
• Remove PPE.
• Perform hand hygiene.
• Don gloves.
• Transport the container to the reprocessing area.
• Remove gloves.
• Perform hand hygiene.
• Thoroughly inspect instruments each time an instrument is processed.
• A magnification lamp is to be used to visualize the instruments for rust, water marks, blood, bioburden, debris, bone, cement, etc. Reprocess the instrument if any of these are found.
• Look for evidence of damage or defects.
• Look for alignment of instruments.
• Check for sharpness, if appropriate.
• Look to make sure the instrument is functioning properly.
• Checking for proper functioning includes opening and testing the instruments to see if they function as intended.
• If instrument identification tape is used, it is important to in-service your staff in its correct application. The Manufacturer’s Instructions for Use for the specific tape being used must be followed, but generally, to apply instrument marking tape one should:
  • Make sure hands are clean and free of oils and grease.
  • Clean the part of the instrument where the tape will be applied with alcohol to remove any lubricant or residue.
  • The tape should be wrapped one to one-and-a-half times around the instrument. Cut the tape at an angle, not straight across.
  • After the tape is applied, steam sterilize the instruments. The heat will assist with the bonding of the tape.
  • The tape is to be applied to the shanks of all instruments. Avoid instrument rings. Wrapping tape one to one-and-a-half times around will not interfere with the closing of most scissor tips.
• Peel package instrumentation per the Manufacturer’s Information for Use. Generally, the peel packages are used for small, lightweight, low-profile instruments.
• Ensure the size and strength accommodate the item being packaged.
• Do not overload the peel package.
• Ensure that they are closed so that all pouch seals are smooth (i.e., without folds, bubbles, or wrinkles).
• Package labels should
  • Be visible and legible.
  • Consist of non-toxic materials and ink.
  • Be written only on the non-porous side of the pouch.
• Use mechanical, chemical, and biological monitors according to Manufacturer Instructions for Use to ensure the effectiveness of the sterilization process. Maintain sterilization records in accordance with state and local regulations.
• Paper–plastic pouches should stand on edge in relation to the cart or shelf, with the paper side of one pouch next to the plastic side of the next pouch.
• Holding racks or baskets specifically designed for paper–plastic pouches may be used.
• Allow peel packages to cool and store on edge.

 

Environmental Infection Prevention and Control

The organization/office needs to establish policies and procedures for routine cleaning and disinfection of environmental surfaces in dental health care settings. They need to use surface barriers to protect clinical contact surfaces, particularly those that are difficult to clean (e.g., switches on dental chairs, computer equipment), and change surface barriers between patients. Facilities should clean and disinfect clinical contact surfaces that are not barrier-protected with an EPA-registered hospital disinfectant after each patient using an intermediate-level disinfectant (i.e., tuberculocidal claim) if visibly contaminated with blood. They need to select EPA-registered disinfectants or detergents/disinfectants with label claims for use in health care settings and follow Manufacturer Instructions for Use of cleaners and EPA-registered disinfectants (e.g., amount, dilution, contact time, safe use, disposal).

 So, those are the basics for dental services. The question I pose to all those reading this article is, are you in compliance and if not, what is it that you need to do to avoid citations in your facility? Remember, the “toothache” is high-level disinfection, and the solution is to “pull” all your policies, procedures, competencies, etc. together and review them so that you do not lose your “smile” during your next regulatory survey.

The second part of this series will discuss dental Water Quality, Amalgam, Imaging safety, Emergency Care Needs Management, Invasive Procedure Consents, Patient Assessment and Discharge Instructions.

To learn more about Regulatory Standards for Dental Practices contact the Courtemanche and Associates Team at 704-573-4535 or email us at info@courtmanche-assocs.com.