July 31, 2020
by Joan Hutchings RN, CPN, BA, MSc, MPA
Infection prevention and control (IPAC) has never been discussed or read about more until now. The pandemic, caused by COVID-19, is having a devastating impact on our world. Will you and your staff carry on business as usual when you reopen? In principle, the answer to this question should be yes but the reality is, the answer will most likely be no.
It is understandable that staff and patients will be concerned about the spread of this infection and their individual safety. Most likely, through meetings and memos important information will be shared, new measures discussed, and changes implemented. If office staff have been compliant with IPAC standards before COVID-19 then a quick review of best practices should be all that is necessary, with closer attention to those related to COVID-19 predominant modes of transmission.
COVID-19 is a respiratory virus which spreads primarily through droplets generated when an infected person coughs, sneezes or by contact with discharge from the nose or mouth. It appears that the virus can also spread through direct contact with contaminated surfaces. It is not certain how long the virus survives on surfaces, but it seems to behave like other coronaviruses. Studies suggest that coronaviruses (including the COVID-19 virus) may persist on surfaces between a few hours and several days. Airborne spread is possible during aerosol generating procedures (AGP).
It has been almost two years since the Royal College of Dental Surgeons of Ontario (RCDSO) published the first edition of the IPAC standards and clinical practice guidelines. There has been a concentrated effort by the dentists to evaluate their office practices, however the focus has primarily been on reprocessing and sterilization. While each of the IPAC standards is important, issues regarding cleaning, disinfection and the use of personal protective equipment pertain directly to the spread of COVID-19.
It follows that all health care providers must follow standard infection and control precautions (SICPs) for all patients during all care in all clinical office settings. As well, staff must be familiar with transmission-based precautions (TBPs).
SICPs or routine practices are based on the premise that all patients are potentially infectious, even when asymptomatic, and that the same standards of practice must be used routinely with all patients to prevent exposure to blood, body fluids, secretions, excretions, mucous membranes, non-intact skin or soiled items in order to prevent spread of microorganisms.
It is recommended that upon arrival at the office, all staff routinely perform proper hand hygiene and continue this practice throughout the day.
Ideally waiting area furniture should be made of materials that are easy to clean with low-level disinfectants. The space should have no non-essential items such as reading materials or toys, items that are known to spread pathogens through direct contact.
All patients should be asked to complete a health questionnaire and all patients should be invited to use an alcohol-based hand rub. Prominently placed signs should provide instructions for the patients to report any recent respiratory illness.
Staff should check each treatment area to ensure that it is ready to receive the first patient. Treatment area should be kept clean and clutter free. Cleaning policy and procedures are to be carefully followed at the end of each day. Specific disinfectants should be used to clean the room, immediate patient area and all high-touch surfaces. Staff must follow manufacturer’s detailed instructions for use (MIFU) guidelines to safely clean dental and diagnostic equipment as well as other technologies used during a procedure. Supplies should be checked for adequate personal protective equipment (PPE) for example, gloves, gowns, masks, and eye protection. PPE must be available for both staff and patients. A final inspection of the room is to be done to ensure that all items are properly positioned, a safe distance from procedure area, to decrease the risk of contamination.
As each patient is escorted into the operatory, staff should put on required PPE in preparation for the procedure. Staff should be encouraged to converse with the patients to reduce their anxiety and fear about infection. This can take place while staff continue to prepare the room and open sterile supplies.
During the procedure, staff should follow IPAC guidelines to decrease the risk of cross contamination. All required items should be specifically placed in advance in order to eliminate the need to touch containers or drawers with gloved hands.
Following the procedure, staff should have the room organized appropriately, to facilitate safe and expedient clean-up of all instruments and equipment. Proper removal or “doffing” and safe disposal of PPE before leaving the operatory must be followed by all staff. In addition, PPE such as glasses provided to the patient must also be properly cleaned and disinfected between patients.
Transportation of contaminated dental equipment and instrumentation to the reprocessing area must follow safe clinical practices. For example, all disposable sharps used during the procedure should be removed and disposed of in the operatory using designated containers. Closed container cassette or a plastic tray with hard plastic cover should be available for staff to carefully place all instruments to prevent injury and to also reduce possible damage to delicate instruments.
Used or contaminated equipment and instrumentation should be delivered to the reprocessing area defined as the “dirty” or receiving side. Used equipment and instruments are to be cleaned in a designated area that is physically separate from direct care areas and from sterile items storage area. The reprocessing area should be physically set-up according to IPAC standards so that there is a one-way workflow from dirty to clean workspace.
All staff working in the reprocessing area must have appropriate training as outlined in the IPAC standards. Staff (dentists, dental hygienists, certified dental assistants) assigned to reprocess equipment should be trained upon hire, at least annually and whenever new equipment or processes are introduced. In addition, staff assigned to reprocess should receive device-specific reprocessing instructions from the device manufacturer’s representative. Staff must follow written policies and procedures that are based on current standards.
The reprocessing of dental equipment and instrumentation involves several important steps that must be carried thoroughly to ensure that sterilization can be achieved. Most offices today are equipped with sophisticated washer/sterilizers, however, if an instrument or piece of equipment is not disassembled properly it cannot be thoroughly cleaned. Proper cleaning is the most important step of reprocessing because protein content of tissues and blood can not be sterilized. If equipment is not properly cleaned, dried and packaged the process indicators will provide misleading information related to sterilization. Staff must be trained and knowledgeable about how to interpret indicators properly.
The process of sterilization is monitored using mechanical, chemical and biological indicators. The purpose of mechanical and chemical indicators is to demonstrate that specific parameters such as temperature, length of time, pressure in chamber, air flow through packaging but indicators do not demonstrate that sterilization has taken place. Only the biological indicator can provide information about the sterilization cycle itself but not for each individual package in the chamber. If too many instruments are packaged together or the sterilizer is overloaded, sterilization of items may be compromised.
Clinical offices should be fully cleaned at the end of every day. Garbage should be collected, floors cleaned, and carpets vacuumed. Supplies should be replaced as required (e.g., soap, ABHR, paper towel, toilet paper, PPE) and sharps containers should be sealed, removed and replaced if full. Items that are high-touch (e.g., doorknobs, telephones) should be cleaned and disinfected, and items that are not high-touch need only be cleaned. Items that are not touched frequently and are not likely to become contaminated do not require daily cleaning, but should receive periodic, scheduled cleaning and disinfection. A cleaning schedule should clearly outline what specifically needs to be cleaned, how often and by whom. It is important that information such as task description, date to be completed and the signature of person responsible is documented.
COVID-19 raises several concerns for office owners. There are questions about the physical design of the office such as ventilation and number of air exchanges per hour, negative or positive pressure in the clinical rooms. As part of employer’s duty, providers should know that they have a role to play in ensuring that a “fit testing” program is in place for those wearing filtering face masks (N95 respirator). Screening staff daily for signs and symptoms of the virus is obligatory. Accurate record keeping of all people that had direct contact with an employee or a patient who is suspected or positive for COVID-19 is a must.
In conclusion, it is a responsibility of dental office owners to provide the right solutions to the challenges posed by patients, staff and health authorities, to provide competent service and to do no harm. If there is a concern regarding compliance with IPAC standards, evaluation from independent consulting services is available and is recommended by the RCDSO. G
About the Author
Joan Hutchings RN, CPN, BA, MSc, MPA, has 35 years of experience in healthcare as a registered nurse, surgical suite specialist and epidemiologist. She is an expert on infection prevention and control practices. Joan was director and clinical instructor of the Operating Room Technique and Management program, a hospital-based surgical program. As a clinical consultant, she provided consulting services and audits to hospitals, outpatient clinics and dental offices across Canada. As an epidemiologist, Joan cofounded SAFE Dentistry Inc., which assists dentists and staff to deliver quality safe services in compliance with IPAC.