Ensuring Safety and Compliance Through Dental Practice Spot Checks

Pop quizzes are the bane of students. The fact that they are unannounced causes fear and anxiety for fear of being caught unaware. But it isn’t just teachers looking for opportunities to frighten students, there are good reasons to have those kinds of tests. Those periodic, surprise quizzes serve a constructive purpose. They show students where deficiencies may exist. The same strategy can help dental practices stay on top of their infection control efforts.

Carrot vs. stick

Jonathan Rudin, DDS, MS, MPH, is a safety and infection control consultant at San Diego Healthcare Compliance, and he observes that conducting spot checks can be useful from 2 points of view: They can both motivate and deter.

“Spot checks are a very good idea,” Dr Rudin says. “They are 2 forms of inspiration. One is as an incentive to create a safe environment to work in. And that is the actual intent of The Occupational Safety and Health Administration (OSHA) – to stay safe. OSHA does have an enforcement department that can impose fines and take legal action. However, OSHA’s overarching objective is toward the safety of employees. The other benefit of spot checks is to help avoid those fines and other legal action. This approach is like being a recruit in military boot camp with surprise spot checks. The recruits must always be ready by keeping everything up to par. So, I recommend creating a safe environment and maintaining it while avoiding OSHA and health department fines and other punitive actions.”

He adds that performing spot checks can provide the kickstart that some practices may need to begin complying with safety, including infection control policies and procedures.

“So many practices seem to be challenged with getting in shape in the first place,” Dr Rudin states. “I would liken it to beginning a physical fitness program where people start out in relatively poor shape. It can be difficult to motivate these practices to take that first step to implement all of the things to get in shape in the first place, much less have a maintenance program.”

Check the record

An easy, effective tool as part of a spot check is simple record keeping. That is, maintain a checklist to eliminate the potential for forgetfulness and other errors.

“Keeping accurate records of adherence to safety protocols is an important way to maintain a consistently safe office.” Dr Rudin observes.

The CDC offers a free app for iOS and Android devices called DentalCheck. It allows the practice to create customized checklists that staff can use to ensure that they aren’t missing anything in the course of infection control efforts.

Checklists include the regular sorts of things that practices should do as a constant part of their infection control efforts. Even though some of those items are routine, they can be forgotten.

“Look through drawers and cabinets where sterilized instruments are stored to ensure that any torn or damaged pouches are removed and re-sterilized,” Mary Bartlett, President SafeLink Consulting advises. “Also, check the external and internal indicators on pouches to ensure that the color has changed to indicate sterilization.

“Spore culture monitoring is a weekly task,” she continues. “If the person who usually does that monitoring is out for more than a week, an alternate person should be designated. This is such an important part of ensuring that the sterilization process is effective. I recommend that a record of the date the monitoring was performed be documented on a log and the results received from the testing lab are matched with the internal records.”

A checklist that she recommends includes:

• Observe staff cleaning and disinfecting treatment rooms to ensure that adequate steps are being taken to remove contamination.
• Infection control training is required by OSHA upon hire, when job tasks change, and annually. New hires should be trained immediately and that training needs to be documented. Check training records to ensure that this training and any future training such as the annual training has been performed.
• OSHA requires that the Exposure Control Plan be reviewed and updated, as needed, annually. Document that review.
• Ensure that all employees who work with potentially infectious items have been offered the Hepatitis B vaccine. If a staff member accepts the vaccine, then make certain that the series has been completed and documented.
• If an exposure incident occurs and the employee agrees to evaluation and follow-up, ensure that the timeframe established by the healthcare professional administering the evaluation is being followed. This can include additional testing for HIV, Hep B, and Hep C a number of months after the exposure.
• A number of steps are involved in waterline safety for the lines in the treatment rooms. If bottled water is installed on the dental unit, then ensure that the water is being changed daily and a chemical is used in the water. Also, shocking of the lines leading from the water supply to the air/water syringe, handpieces, and Cavitron should be performed at a minimum monthly. The actual testing of the waterlines is typically recommended to be performed quarterly.
• Sharps containers show a “fill” line so check to see that they are not being over-filled.
• In some states, biohazard waste must not remain in the practice beyond a certain period of time, so someone should check to ensure that it is being picked up or disposed of on a timely basis.
• Anesthetic carpules and needles contain an expiration date. Check drawers where these are usually stored to ensure that they are not beyond expiration.
• Dates for changing the solution in the ultrasonic equipment should be noted and adhered to.
• Autoclave maintenance must be performed on a regular basis. Keeping logs to ensure that this maintenance has been performed will help to document that it is being performed.
• It’s not often that a cold sterilant is used, but if it is, it usually has a time period between changes. Mark a date on the container and ensure that the solution is being changed according to that date.
• Shortages of personal protective equipment (PPE) have gotten better, however, a good inventory needs to be maintained so establish a minimum inventory and check it to ensure there’s adequate inventory at all times.
• Observe the donning and doffing of PPE to ensure it is correct to prevent cross-contamination.
• Ensure that employees are wearing the PPE that has been determined the best protection by the dentist and are wearing it correctly.
• Observe recapping techniques to ensure that the method and/or mechanical device is being used correctly to prevent needle sticks.
• For protection from COVID-19, practices should continue to perform employee, patient, and visitor screening. Ensure that this screening is taking place.
• Ensure that single-use devices are discarded after one use and are not used on more than one patient.

“In 2016, the CDC published the Summary of Prevention Practices in Dental Settings as a guide of basic infection prevention recommendations,” Bartlett says. “A recommendation was the assignment of at least 1 individual trained in infection prevention to be responsible for coordinating the program.Monthly monitoring helps recognize where improvements are needed rather than waiting for a year between reviews.The Infection Prevention Checklist provided with this Summary as Appendix A is an excellent tool to use to develop a checklist for the spot checks.”

Spot check répertoire

Spot checks can identify a broad spectrum of safety issues. Dr Rudin is rarely surprised by the things that he observes when he performs his own inspections.

“For example, if a practice has more than one autoclave, they should indicate on each sterilization pouch two critical bits of information: the autoclave it was processed in and the date of processing,” Dr Rudin says. “I often see pouches that do not indicate what date they were processed on and in which autoclave. The reason that identifying both the autoclave and date of processing is important is so that a failed spore test -- the gold standard for testing autoclave function -- will enable the practice to pull all instruments out of circulation that had been processed in the failed autoclave.”

Spot checks don’t supplant implementation of safety protocols and infection control efforts. Their use should is part of the process.

“It may be difficult to limit your spot check to just a few aspects of your safety practices. To cope with a large number of areas to check, consider breaking down the overall task by region and do a 20-minute check on just that area. Then the next day you would spend 20 minutes on another area.”

Spot checks need not be long, laborious procedures. Something that’s both achievable and consistent is best.

“I think the important thing is to do safety spot checks on both a consistent and sustainable basis,” Dr Rudin observes. “If it’s small bites at the apple, so to speak, that’s sustainable. It’s not a huge burden. A busy practice doesn’t want to close down while somebody is going through for an hour to do a comprehensive inspection. Spending 20 minutes a day, going region by region when time permits would help keep people on their toes.”

Spot checks aren’t ‘Gotcha!’ opportunities. Rather, they can help the practice improve its safety measures and lesson its chances for sanctions when inspectors come through.