by NOELl KELSCH, RDHAP
In cases where disasters strike, it is vital to have your plan of action in place. Facing those disasters head-on can be the difference between patients continuing care, having a great understanding of the process of infection control, or developing a phobia and not being able to enter the dental environment. What I consider a national disaster was presented on March 28. This news brought forth the concept that entering the dental environment could be more risky than living with dental disease. An oral surgeon's lack of infection control standards may have infected over 7,000 patients. Your choices in infection control can and do impact your patients' lives forever. Your reaction to these events can impact patients for years to come.
So What Happened?
In Tulsa, Okla., breaches in infection control standards has led to the need for 7,000 patients to be evaluated for the presence of disease. They were all treated by the same oral surgeon's office. It is suggested that this case came forward because of a suspected case of hepatitis C transmitted to a patient.
The oral surgeon is suspected of using single-use vials of medication on multiple patients. This leaves patients at great risk. Dental vials can be a source of cross contamination of bacteria and viruses. They can also be involved in paraesthesia if you use a disinfectant to wipe them down after they have been on a patient tray. They have a semi-permeable membrane that disinfectants can pass through and cause paraesthesia. This dentist was also allowing unlicensed individuals to deliver care (intravenous medication) that requires a license. Rusted instruments were discovered upon inspection. As we all know, rust can inhibit the sterilization process.
We all know that any of the above scenarios can spread disease. This all could have been prevented if the office had their written infection control protocol in place and implemented it; but they did not.
Previous example of disease transmission
Previously, it has been clarified that disease can be spread in the dental environment. This is not a first for dentistry. For example, the Journal of Infectious Diseases reported a patient-to-patient transmission in a dental setting in 2001. The state health department's epidemiologic investigation found that the patient had none of the traditional hepatitis B risk factors. The only transmission factor was a recent oral surgery. An investigation of the oral surgery practice where the patient received care disclosed that another surgical patient earlier that same day was on the state's reportable disease registry for hepatitis B. Testing with a molecular epidemiologic technique revealed that the transmission did occur between the two patients.
The hard part here is when they investigated the office and monitored all the infection control protocols, the office was following standard infection control practices. The staff was hepatitis-B free and had been vaccinated. The investigators could only speculate that a lapse in procedures had occurred after the source patient left the area contaminated with blood. This and other cases remind us all how imperative infection control protocols are. This reminds us that our infection control is only as good as the worst action we take.
An Opportunity to Review
You may think this is an event that could never happen in your practice. My question is, have you looked closely? Are you evaluating your practice? Do you have a written infection control protocol in place? Are you aware if your practices are up to date?
Infection control is never static. Most states require infection courses, and OSHA requires a yearly blood borne pathogen training in all dental offices. It could be a very simple thing you are doing. Are you wiping down dental carpules that went on a patient tray and were not used? Do you use cold sterile single-use items that are not able to be heat sterilized and were intended for single use? If you are reusing single-use items, you are delivering the same level of care as the oral surgeon in Tulsa. The reason these items are single-use medical devices is because there is no guarantee they are disease-free after use.
Some Things to Think About and Act Upon
I recently had an audience member during a lecture share with the audience that she had substituted in an office where infection control was so incongruous that she stopped what she was doing several times during the day to correct the assistant. I asked her what she did about the situation and she stated, "Nothing. I just never went back."
We all have a responsibility. We are the voice of patients that may or may not know about the situation. When we agreed to "do no harm," that includes infection control. It is our responsibility to report and to be a part of the change. What do you need to change?
All offices should use the nonprofit Organization for Safety, Asepsis and Prevention (OSAP) tools and materials. The workbook "From Policy to Practice" delivers all the concepts in a practical manner. They have great resources for you to review your practices, and the OSAP website is always up to date with its information. Membership to this organization is very inexpensive. They are dedicated to making sure patients and staff return home safe at the end of the day.
All offices should have a written infection control program in place. Where is yours located? Who is in charge of making sure it is updated?
All states should require anyone who steps on the clinic floor to have formal infection control training. California requires that an unlicensed dental assistant take an eight-hour course in infection control; most states do not require the unlicensed dental assistant to take any courses. Advocate in your state to make infection control required for anyone who is delivering patient care.
All offices should be reviewing the updates from the Centers for Disease Control and Prevention regularly and utilizing the resources for infection control on their website.
Before we refer any of our patients, we need to know where we are sending them and that the othger office is practicing the same level of infection control that we insist upon.
What Should I Say To Patients?
Being aware of patients' need for reassurance is a fundamental part of dealing with this challenge. Refusing to discuss the situation exacerbates patients' apprehension and can leave them feeling vulnerable.
Reassure: When patients ask questions, reassure them that their questions are appreciated and that you are doing everything to keep both patients and health-care professionals safe. Let them know that these incidents are few and far between but that your office has done everything necessary to keep this scenario from occurring, taking steps from continuing education to daily checklists.
Questions: When a dentist at the Veterans Affairs Medical Center in Dayton, Ohio, was lax in infection control and potentially exposed hundreds of patients to blood borne pathogens, the related newspaper articles led to dental office's phones ringing off the hook. Patients wanted to know if they were safe in the environment that the dental office creates. Each of us has to have those answers in place before an event occurs. Here are some common questions that have come up during those times:
1. How do I know that your office is complying with all the infection control rules
Your safety is always our first concern. We have an ongoing program, a daily check list, and training built into our practice. We monitor at every level, from the sterilizer to the procedures that the staff is doing to clean the room. We take an OSHA course annually, and we update our information with materials from the Centers for Disease Control and Prevention as they come out.
2. I read that dental drills are a source of disease. How do I know yours are safe
All of our drills are cleaned of debris and then heat sterilized in a sterilizer. The units that you read about were not heat sterilized. We do not have any drills that are not heat sterilized.
3. How do I know you are sterilizing instruments correctly
We follow all the protocols for sterilization and monitor them step-by-step. In our practice, we use three methods to assure that sterilization has occurred. We have a system in the sterilizer, a system on all our bags or wrapped cassettes, and we send out a weekly spore test to make sure the system in working. All of our equipment and bags or wrapped cassettes are FDA-approved as medical devices, and we follow the Centers for Disease Control and Prevention recommendations in all steps of the process. We open the packages in front of you so you can be assured they are safe, and we can show you the indicator we use.
4. I read that the instruments in the Tulsa case were rusted. Why did that matter and are your instruments rusted
The areas where rust occurs on an instrument do not allow the sterilization process to work properly. We use stainless steel products to avoid rusting. If rusting does occur, we remove the item from service before it leaves sterilization so there is no risk to the patient.
5. How do I know you are keeping me safe
Our office uses barrier protection and disinfection for each and every patient regardless of their health status. We use disposable items to limit the chance of cross contamination. We heat sterilize all our instruments, or they are single-use and we dispose of them. We follow all the protocols for keeping our patients safe, including washing our hands, wearing personal protective equipment, and not allowing sick staff to come to work. You safety is our first concern.
6. Can I see the sterilization area
Patients are welcome to view all areas of our offices as long as we can be compliant with infection control and HIPPA laws. I can take you from the start of the process to the end so that you can see how dedicated we are to your safe care.
Having plans in place for incidents such as the Tulsa event should be part of your infection control plan. You can help patients understand the measures you take and reassure them they are safe in the dental environment. This event can be an opportunity to educate, to change infection control protocols, and to impact your patient's infection control perception of your office. As you make infection control decisions every day, you can be an advocate to stop this from happening again. RDH
What to review with patients
OSAP came up with this great list of infection control concepts to review with patients. This is something that you could adapt for your office and print for patients:
- Inform patients that the practice uses evidence-based infection control precautions as recommended by the Centers for Disease Control and Prevention. The latest recommendations and other resources can be downloaded from the CDC.
- Explain that dental anesthetics are provided using sterile single-use needles and cartridges of anesthetic and that these items are properly discarded after each patient.
- If IV medications are used, explain that these medications are either from single-dose vials, or multi-dose vials are accessed only once with a single needle and syringe, and that additional medications, even for a single patient, are drawn with a new syringe and needle.
- Explain the sterilization process, including thorough cleaning, examination and then sterilization of instruments.
- Reassure patients that instruments are maintained in sterile pouches or wraps until they are needed for patient care. It may be particularly useful to only open pouches once patients have arrived, so they may see for themselves that the instruments are properly packaged.
- Discuss the processes used for sterility assurance, including chemical indicators on and/or in packs of instruments, and the regular monitoring of the sterilization process though the use of a biological indicator (spore test).
- Reassure patients that all procedures requiring licensure or certification are provided only by professionals licensed to provide those services. More information may be found through the American Dental Association at www.ada.org.
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.
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