Diana is a 25-year-old dental hygienist who loves her profession, her peers, and her patients. However, she wasn’t so sure about the practice where she worked. Dr. Evans’ office was the first she worked in since graduating three years ago. When she interviewed, she was hesitant to ask the questions her instructors and advisor suggested. She was afraid that certain questions on health, safety, and infection control might be confrontational and prevent her from getting the position. Not long after starting, she noticed subtle infractions in infection control that became more apparent as time went on. She became discouraged and began quietly seeking a new position, and promised herself to ask the hard questions. After all, the safety of her environment was critical and errors in her current office strengthened her belief.
For Diana, the final impetus to change offices was when a dental assistant was jabbed with a needle that was incorrectly passed to her. The assistant was blamed for the accident, not the dentist who didn’t follow appropriate work practices. The dentist glanced at the puncture wound, deemed it insignificant, and did not allow the assistant to do more than basic first aid. No one questioned the source patient and the injury went unreported. Although Diana knows that most injuries do not lead to bloodborne infection, this situation was quite disturbing and the topic of many whispered discussions among staff members. Morale became low. Diana wondered, “What if a bloodborne pathogen had been transmitted, and what if the injury had been significant?”
So Diana researched through the Web sites for CDC, OSAP, and HIVDENT. What she learned was eye-opening. First, most injuries are preventable if appropriate work practices and engineering controls are used. Some injuries are accidental, such as those caused by an inadvertent movement by a patient or a device that doesn’t work. As Diana reviewed guidelines, including the Guidelines for Infection Control in Dental Health-Care Settings - 2003 from the Centers for Disease Control and Prevention, and articles on post-exposure management, she realized that the proper actions to assess and follow up occupational exposure simply weren’t happening in her office.
Feeling educated and empowered, Diana plans to interview potential employer practices and not just be interviewed for a job. She feels confident that her instincts and knowledge can help her assess practices and address her concerns. Her concerns are:
• Is there evidence that safety is a concern to the staff?
• How are tasks performed? Are safety devices and procedures in place? What chemicals are used and how are they stored? Is there an eyewash station, what is the sterilization area like, and are emergency phone numbers posted?
• Are there reference books and office-specific manuals regarding safety?
• Is there one person designated as an infection control manager?
• Is there an office-specific infection control manual? If so, how recent are the updates, and has staff been trained on the procedures and protocols?
• Can the infection control manager adequately answer questions regarding employee training in infection control, and is there a designated health care professional in case of an occupational exposure?
Diana learned there are many employment opportunities for her, but she must advocate for herself whether or not employee safety is ensured.
According to the Centers for Disease Control and Prevention, occupational exposures should be considered urgent medical concerns. They should be immediately and appropriately evaluated to determine the recommended course of action. In order to accomplish this, all dental practices should have procedures in place for post-exposure management, including a written manual reflecting the most current United States Public Health Service (USPHS) guidelines for managing bloodborne exposures. All staff should be trained in preventing and managing occupational exposures to blood and other potentially infectious materials, know whom to report to, know basic first aid, know how to immediately access a qualified health care professional, and know what treatment may be necessary.
It is far better to prevent injury than to deal with the consequences. Prevention includes engineering controls (safety devices), work practice controls (habits), personal protective equipment (task-specific), and administrative controls (written protocols). Worker education and training is key to preventing occupational exposures. Should an injury occur, it is essential for employees to know the steps to contain and manage the injury, including the timely (within two hours) use of post-exposure chemoprophylaxis if indicated.
An office-specific policy of post-exposure management should be written and based upon the most recent USPHS recommendations. The policy should identify the practice’s qualified health care provider, who should be familiar with USPHS recommendations for post-exposure management of bloodborne pathogens and with the OSHA Bloodborne Pathogens Standard. The manual should also explain how to report an injury and the forms necessary to complete the report. Reporting should not interfere with timely access to the qualified health care professional.
In summary, the self-reported rates of injury among dentists are low and have decreased over the past decade to about 2.2 dentists per year. Most injuries are preventable. But when an injury does occur it should be viewed as an urgent medical concern and should receive immediate treatment and follow-up. It is imperative to be familiar with your employment contract and to determine whose obligation post-exposure management is in the event of an incident. This should not be determined in the midst of an emergency, but known well in advance. It is particularly important if one is employed by an agency and provides services in several dental offices.
Recommended reading and resources:
1. OSHA Exposure to Bloodborne Pathogens Final Rule, December 6, 1991 (29CFR 1910.1030). Revised January 18, 2001 as published in the Federal Register.
2. CDC: Updated U.S. Public Health Service guidelines for the management of occupational exposure to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR 50 (No. RR-11), 2001
3. CDC: Guidelines for infection control in dental health-care settings - 2003. MMWR 52 (No. RR-17).
4. OSHA: www.osha.gov/SLTC/dentistry?control.html and www.osha.gov?OshDoc/toc_fact.html
5. OSAP: www.osap.org
6. HIVDENT: www.hivdent.org
7. CDC: www.cdc.gov/mcodpd/hip
8. National Clinicians’ Postexposure Prophylaxis Hotline (PEPLine): www.ucsf.edu/hivcntr , 888-488-4911
9. Needlestick!: www.needlestick.mednet.ucla.edu
Elements of a post-exposure report include:
1. Date and time of exposure
2. Details of procedure performed:
a. Where and how the exposure occurred
b. Type of device involved
3. Details of the exposure such as type of fluid or material and severity of the exposure.
4. Details on the source patient such as history of bloodborne disease
a. If infected with HIV, current viral load and medication history.
b. Hepatitis B or C status
c. Any other significant health information
d. An informed consent for testing
Elements of post-exposure management:
1. Primary first aid
2. Referral to a pre-selected health care professional who is knowledgeable about the delivery of oral health care services; is competent to manage, counsel, and refer for lab tests; and can provide medical follow up in accordance with the most current USPHS recommendations
3. Follow-up as indicated by the qualified health care professional
4. Report of the incident within 15 days to employer stating that follow-up occurred and whether HBV vaccine was administered. The remainder of the report is confidential between the QHP and the employee
5. Testing, with consent, of the source patient
1. Temporary Workers: The responsibility for post-exposure management is shared between the agency and the dental office. The agency is required to ensure that all temps have been vaccinated and to provide their follow-up care. The office should provide necessary PPE and immediate first aid.
2. If the exposed worker is an employee of the office, then the employer is responsible for the costs of post-exposure management, but not the cost of long-term treatment should infection occur.
3. Consult with your State Worker’s Compensation laws and complete any required report forms.
4. Review OSHA obligations, federal or state as applicable and complete any required reports or forms.