The Most Overlooked Areas of Infection Control

Infection control is a multifaceted discipline. That is, it is a war waged on several fronts—personal protective equipment (PPE), hand hygiene, instrument processing, and so forth. Regrettably, not all areas get the necessary attention, and some are often overlooked and neglected. Taking a moment to identify those areas can be helpful to avoid infection risks or even regulatory body fines.

PPE

Thanks to the pandemic, PPE got a lot of attention—for both better and worse. On one hand, it shined a spotlight on the necessity and utility of PPE. On the other hand, fluctuating recommendations led to confusion. And as we seem to be coming out of the pandemic, infection prevention speaker, author, and consultant Mary Govoni, CDA, RDH, MBA, notes that some offices seem to be reverting to pre-pandemic practices.

“That’s always a bone of contention with many practices,” Govoni says. “There are a lot of practices that are still reusing their face masks—like they were allowed to do during the pandemic when we had such a shortage of masks and respirators. They don’t understand that we have reverted to the original use of face masks and respirators as disposables. In other words, one patient, 1 mask, or 1 respirator. There also are a lot of practices that are trying to—if they’re wearing respirators—preserve them by putting a face mask over them, and OSHA [Occupational Safety Health Administration] and the Centers for Disease Control and Prevention (CDC) have both said that that is not a good idea. Now we don’t have this shortage. In some cases, putting the mask over the respirator interferes with the seal on the respirator, so it might pull a little bit too hard and break the seal.”

Safety First

Being mindful of safety doesn’t just involve processes and procedures going on chairside. Overall safety measures within the practice can help stave off problems. For instance, safely transporting sharp, dirty instruments from the operatory to the sterilization center is often overlooked.

“Once the procedure is over, anything that can be thrown away in the operatories should be discarded in that location,” Jonathan Rudin, DDS, MS, MPH, observes. Dr Rudin is a safety and infection control consultant at San Diego Healthcare Compliance. “The kinds of things that should be disposed of in the operatory include onetime use items, like suture needles, injection needles, and disposable scalpels — essentially, anything that would not ordinarily be run through the autoclave. Even worn-out burs and those designated as onetime use are supposed to be discarded in the operatory. People need to remember that burs are discarded in sharps containers because they’re sharp enough to go through a plastic bag and stick somebody, causing an exposure incident. Therefore, the only things that are transported to the sterilization area for reprocessing are the instruments actually intended for sterilization. The reason for this practice is to minimize the quantity of biohazardous material that gets transported through the hallway. That way, if there were an unfortunate collision between the person transporting the contaminated instruments and somebody else, the amount of biohazardous instruments and material that could go flying has been minimized.”

Regrettably, too many practices overlook this important safety measure.

“Many dental health care workers seem oblivious to the practice of discarding contaminated, onetime-use items in the operatory,” Dr Rudin says. “They started their incorrect behaviors early on in their careers and have practiced those bad habits through the ensuing years. While it may seem to be more efficient to throw all the sharps into a centralized sharps container, it is considered a safer practice to, instead, place the sharps in individual containers located in each operatory.

Sterilization

“Once the instruments intended for sterilization are brought to the sterilization area, they are placed in the ultrasonic machine,” Dr Rudin says. “The person processing the instruments in that area should be maximally protected. That includes wearing everything that you could possibly think of eye protection; face shield, respirator mask, gown that is liquid-resistant, rubber apron, and utility gloves.”

It’s not enough to simply use a mask and gloves, as is often seen in practices. Gloves must be the right type and size for the operator.

“My recommendation is to always find the thickest correctly sized gloves that provide the dexterity needed to do the job well and safely,” Dr Rudin says. “It seems that manufacturers don’t make utility gloves in small enough sizes for a lot of the people doing the sterilization. It is recommended to search for the correctly sized, thicker, and more protective utility gloves.”

“Anybody wearing utility gloves should recognize that they are still vulnerable to an exposure incident,” Dr Rudin notes. “That is, a sharp, contaminated instrument could go through the thicker, more protective utility glove. The major warning here is that while utility gloves are more protective than typical exam gloves, they are not foolproof. You still have to exercise an extreme amount of caution when handling contaminated instruments.”

Disinfection

The term “out of sight, out of mind” is certainly cliché, but it has no place in infection control—to wit, dental unit waterlines. They’re easy to forget, but they provide the opportunity and the environment to harbor dangerous bacteria.

“Many practices are not testing their waterlines on a periodic basis,” Govoni observes. “We don’t really know what ‘periodic’ means. That’s the term the CDC uses in its guidance, but OSAP [the Organization for Safety Asepsis and Prevention] says it should be done quarterly. Practices are using all kinds of products, waterline disinfectants, cleaners, and so forth, but they don’t really know if they’re effective unless they’re testing to see if they meet that 500 CFU quality standard.”

Surface disinfection may seem like a straightforward enough chore, but there are an infinite number of wrong ways, and only 1 right way.

“A lot of times, I see team members taking a wipe, and they’re just going in circles around and back and forth over surfaces, where they may not be doing as good of a job of either removing debris or applying disinfectant,” Govoni says. “They should always use their wipes in 1 direction: from right to left or left to right, but not going around in circles and going back over another surface that they’ve just cleaned, because they may be re-contaminating it.”

Why are Things Missed?

Why do practices tend to overlook certain areas? Is it because practices just get into bad habits? Is an area not popular enough to garner the appropriate attention? Is it something else?

“I think it’s a combination of things,” Govoni observes. “One is that many times the dental team members are just unaware that it is a recommendation or that it’s a necessary procedure—if they haven’t been appropriately trained to know what they need to do, or they don’t continue to stay in touch with what the CDC is recommending to us.”

Misunderstanding the CDC vs OSHA requirements can be another component.

“I emphasize the CDC because those are the guidelines that we need to follow for patient safety,” Govoni says. “OSHA doesn’t so much address decontaminating the treatment rooms in terms of worker safety. It’s really falling under the CDC to recommend what we need to do for patient safety. In some cases, the belief that what the CDC recommends is voluntary. They don’t have to do it because OSHA doesn’t say they have to do it. And so there still remains that misunderstanding that OSHA is all about worker safety. CDC is not only looking at worker safety but patient safety as well. I just finished a research project looking at what state dental boards say about CDC guidelines. Forty out of the 50 states, plus the District of Columbia, say that either all or some of the CDC guidelines must be followed. Otherwise, that’s a violation of the dental license rules in the state.”

Practices can check their work to ensure that they’re providing a safe environment by conducting regular spore testing for their autoclaves.

“One of the best ways to know that they’re having problems is that their autoclave’s spore tests fail,” Dr Rudin says. “If the spores in the test sample are destroyed by running through the autoclave, then we conclude that the autoclave is functioning properly.”

However, he observes that many practices get in the habit of relying to a great extent on the chemical indicators on pouches and tape to validate that sterilization has occurred. Chemical indicators—those spots on pouches and diagonal lines on the tape used to hold cassette wrapping paper closed—are not reliable indicators of sterilization. Instead, these chemical indicators should be interpreted to mean that failure to change color is an indicator that sterilization has not occurred. Assuming that the color change means sterilization has occurred is incorrect.”

In the world of infection control, there a lot of balls to juggle. But, like any juggling act, it’s important to pay equal attention to all the parts so nothing falls through.