BY Noel Kelsch, RDHAP, BS
For the past year, I have conducted surveys online and with my speaking audiences about infection control issues in the dental office for clinicians. In the next few articles, I will review some of the findings from these surveys. I have received 2,400 responses that are both reassuring and concerning at the same time.
Hands down, the least understood area is the use of surface disinfectants. Simple changes in the way that surface disinfectants are managed can impact the lives of clinicians, as well as the lives of our patients. What an opportunity for change!
Reading the label: One of the areas the Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA) focuses on is the importance of understanding the steps for the use of a product and the protection that is necessary in its use.1 From ventilation to personal protective equipment, each area impacts outcomes. The labels can frequently change, and often those changes will include vital information, such as the exposure time to kill viruses and bacteria. The EPA examines and evaluates:
• Ingredients of a pesticide
• Where it will be used (medical setting, in the home, or on food)
• Amount, frequency, and timing of its use
• How it will be discarded or stored
This is all included on the label use and is available on the EPA website in great detail: http://iaspub.epa.gov/apex/pesticides/f?p=PPLS.2
Questions and Solutions: When clinicians were asked if they were reading the label, the replies made me realize how important it is to get the message out that all new shipments must be evaluated for changes in the label directions. When asked, "Do you read labels on hospital-grade disinfectants before using them?" 61% stated yes and 39% stated no! The most common comments were, "I only read the label if using new products" and "We have used the same product for years." The most insightful response included bringing the product into the morning huddle and reviewing it with the entire staff. Product labels change, and we must read them each time a new shipment comes in. Yet, 92% said they were not reading the label if they have used the product previously! At each morning huddle, bring in a product and review its uses, precautions, and label directions.
Many clinicians did not understand the basic concepts of the cleaning and disinfection process. When asked, "What is the minimum number of wipes it takes to process a room?" 14% thought that they could use one wipe and 20.5% stated that they did not know. Review the two-step process of cleaning and disinfection with the entire staff. Explain the importance of clean, toss, new wipe, disinfect. A study from Cardiff University clearly showed using a one-step process, as opposed to a two-step process, can simply spread the debris rather than kill the pathogens. You must clean first and then disinfect.3 Debris present on an object or surface can stop the disinfection process. There was also confusion about high alcohol content in products. Many said the higher the alcohol content, the better the product. It is important to note that if you are using a product as both a cleaner and a disinfectant with too high of an alcohol content, it will not clean well and will dissipate very quickly. Evaluate your needs and match your products.
Following the Label Directions: Following the label directions on an EPA-registered disinfectant is not just a suggestion; it is required by OSHA and the EPA. It is the only way you can be assured the product will be effective and the staff will be safe. Staff must be trained on how to use the product and they must comply with that training. No one should use products in any way other than what is specified by the labels. There are reasons for every direction included with a product.4,5
Questions and Solutions: 29% of the clinicians did not know if they were following the label directions or were in compliance with FDA regulations. Shockingly, 23% reported that their offices store cotton 2x2s in a jar with disinfectant or antiseptic. Storing disinfectant in a jar with 2x2s can render the disinfectant useless. The bleach in the 2x2s is known to impact the effectiveness of disinfectants.6 Schedule training on any new products and any old products that have changed. Ongoing training on the use of products and the precise following of directions is a simple solution to these challenges.
Surface disinfectants are required to be Environmental Protection Agency (EPA) approved and the EPA number must be listed on the label. The label will also state if it is a hospital-grade disinfectant. The EPA number lets you know that the product is either low-level (such as HIV and HBV label claims) to intermediate-level (such as tuberculocidal claim) activity. We must use an intermediate-level disinfectant for anything visibly contaminated with blood.
Questions and Solutions: When asked if the product that they were using was an EPA hospital-grade disinfectant, the overwhelming reply (81%) was, "I do not know." Over-the-counter items from big-box stores and grocery stores more than likely do not have EPA registration numbers as a hospital-grade disinfectant and cannot be used in the dental setting for cleaning and disinfecting. Twenty-eight percent were buying disinfectant over the counter. Check to see if your product is a hospital-grade disinfectant approved by the EPA. Train all staff in what to look for in purchasing an EPA-approved disinfectant.
Personal Protective Equipment: A vital part of keeping the clinician safe is following OSHA regulations and CDC recommendations for using proper personal protective equipment. Sharps and chemically resistant gloves are required when using a disinfectant to break down a room or work in the sterilization area. Patient exam gloves are not designed to meet the harsh requirements when working with chemicals; they were made to work with patients. I reached out to Kimberly Clark Company and asked about their patient exam gloves and working with disinfectants. A representative from Kimberly Clark stated, "I have consulted with our technical team regarding your question about exam gloves that are chemical resistant. Our chemical gloves are different from our exam gloves and have a much thicker mil than exam gloves. However, our health-care division does have some gloves that will protect against certain chemical exposures during health-care procedures, such as chemotherapy drugs. They are not designed to work with disinfectants." There are no patient exam gloves on the market that are chemical and sharps resistant.
Questions and Solutions: 79% of those surveyed wear masks when working in the sterilization area or working with chemicals, and 81% wear gowns. Sadly, only 20% are consistently wearing utility gloves. Therefore, an overwhelming 80% are putting themselves at risk for sharps injuries and their organs at risk for chemical exposure by not wearing utility gloves. Exam gloves are not resistant to chemicals and can allow them to penetrate to the skin. The excuses for not wearing utility gloves remind me of when I first donned gloves in the late '80s: "They destroy my tactile sensitivity," "They are too bulky," or "I don't have the time." Overwhelmingly, it was stated they thought patient exam gloves were enough; they are not. Some even reported they were touching chemicals with their bare hands since they were using a disinfectant wipe that was "safe." The disinfectant wipes are made to kill microorganisms; they are not safe for human contact! A few very honest people shared that they were just lazy. This is not an area to be lax in. Of the 80% that were not wearing utility gloves, 11.25% reported a sharps injury within the year. Of the 20% that were wearing utility gloves, only .05% reported a sharps injury! Such a significant difference! Talk to your sales rep and ask for samples. Find the pair that fits each clinician, is flexible and easy to take on and off, and purchase enough pairs so each clinician can have their own. Many companies make utility gloves that are autoclavable.
Understanding the use of surface disinfectants in the dental setting is vital and a real chance to make a change. RDH
1.From Policy to Practice, OSAP's Guide to the Guidelines, 2003.
3. www.cardiff.ac.uk, accessed 9.12.2014.
5. Rutala W. Disinfection, Sterilization and Antisepsis Principles, Practices, Current Issues and New Research. APIC Conference Proceedings, 2006, APIC. Page 13.
6. Molinari and Harte. Practical Infection Control in Dentistry, 3rd. Edition. Kluwer/Lippincott/Williams & Wilkins Publishers. 2010. Page188.
NOEL BRANDON KELSCH, RDHAP, is a syndicated columnist, writer, speaker, and cartoonist. She serves on the editorial review committee for the Organization for Safety, Asepsis and Prevention newsletter and has received many national awards. Kelsch owns her dental hygiene practice that focuses on access to care for all and helps facilitate the Simi Valley Free Dental Clinic. She has devoted much of her 35 years in dentistry to educating people about the devastating effects of methamphetamines and drug use. She is a past president of the California Dental Hygienists' Association.