Taking control

INFECTION control is a high-profile issue for dental services and one that has inspired considerable media coverage in recent years as well as numerous case histories in dental journals.

But while decontamination has been a more contentious issue for dentistry since the introduction of HTM 01-05 requirements by the Department of Health, it’s important not to overlook other aspects of infection control which are just as significant in terms of patient safety.

Three areas of infection control that cause most concern to patients and patient safety organisations are hand hygiene, the use of personal protective equipment and the re-use of single use items.

Despite it being the basic first step in achieving infection control, evidence suggests healthcare professionals still don’t apply hand hygiene as consistently as they should. Good hand hygiene before and after patient treatment episodes, in conjunction with wearing and changing disposable gloves, is an essential requirement for all dental care professionals and is the cornerstone of good infection control.

Similarly, dental personnel must also know their responsibilities in terms of the safe use of personal protective equipment such as surgical masks, protective eyewear and protective clothing.

Single-use items reduce the risk of patient-to-patient transmission of infection but policies on their use differ across the UK. In Scotland in 2004, endodontic instruments were designated high-risk items after research showed endodontic fi les couldn’t be cleaned effectively, thus raising the risk of residual contamination with nerve tissue and potentially prions. Based on this evidence, disposal of endodontic files after single use was deemed essential north of the border.

However, the situation in England differs. Following a review in 2010, re-use on the same patient at subsequent visits is considered acceptable providing they are marketed as re-useable and stipulations for re-processing and traceability are adhered to precisely.

What remains clearly unacceptable anywhere in the UK is the re-use of equipment carrying the single-use symbol, as this would breach requirements set out by the Medicines and Healthcare products Regulatory Agency.

Key to the consistent application of infection control precautions is providing adequate dental equipment. Problems can arise if practice owners or management fail to provide or restrict the use of items essential to meet the standards. No dentist would want to be on the receiving end of a complaint from a concerned team member who has been obstructed in attempting to apply current standards.

Decontamination

Decontamination is still an emotive subject for general dental practitioners across the UK. Over the last few years there has been a gradual change in attitude from disbelief to a disgruntled acceptance that these requirements are not going to go away.

When HTM 01-05: Decontamination in dental care practices was finally published by the Department of Health in 2009, the same general principles were applied south of the border and in Northern Ireland. The difference in the details of the guidance and differing timescale are contentious and are unlikely to be resolved soon. Compliance in decontamination is complex but the general principles are:

• A separate LDU facility

• Process documented and applied

• Decontamination equipment installed, validated, tested and maintained

• Quality management system

• Documented training.

The main focus has been on the need for a local decontamination room outside the clinical area. In Scotland in 2007 the details of Local Decontamination Unit (LDU) design were set out in Scottish Health Planning Note 13. Although the general principle of the facility design was unchanged, the scale and the preferred option of the two-room models posed significant difficulties, particularly for those already challenged in terms of space. The preference for a two-room LDU was based on a need for risk reduction as the one-room model risks clean and dirty instruments becoming mixed up.

There appears to have been a slow acceptance by the healthcare authorities that this may have been unrealistic for the majority of dental practices. Although two rooms remains the preferred option, recent discussions indicate a one-room model following the design principles of Health Facilities Scotland’s SHPN13 guidance will be acceptable.

The critical requirement within the one-room LDU is that processing must be carried out correctly and consistently by all staff. The decontamination process includes transport, segregation, cleaning, inspection and sterilisation of reusable items. To achieve this, written policies and procedures must be in place and must be understood by all staff involved in decontamination.

Training for the whole dental team is essential to ensure decontamination processes are applied effectively and that each person knows their role and is competent to carry it out. Apart from the GDC requirement for all registrants to have five hours training in a five year CPD cycle, it is essential that decontamination is part of new staff induction, with regular updates for the whole team.

Decontamination equipment, essentially the bench-top steriliser, has been used for many years in dental services. But focus has shifted more recently to the potential risk of prion contamination which requires a higher standard of instrument cleaning. Compliance requires the use of a washer disinfector while manual cleaning should only be used for items incompatible with automated processing.

All decontamination equipment should be installed and validated before use, with testing and maintenance carried out according to the manufacturer’s instructions. Audit is another essential element to assure both the practice and external agencies that all processes are being applied consistently and effectively.

The future

One question frequently asked by dentists in Scotland is what will happen if they can’t/don’t/ won’t comply? By 31 December, 2012 all health boards will be required by the Scottish Government to report on decontamination compliance in dental services. The fate of those who are noncompliant is not clear.

Compliance is likely to be reviewed through a new practice inspection document which is currently being developed. This will look at details of requirements for decontamination facilities, equipment and processes. It is hoped health boards will retain the responsibility for inspections as part of the requirements of current terms of service. The role of other external organisations in this process is still not entirely clear.

After the significant changes introduced in recent years it is clear that a period of consolidation would be welcomed. A need to review existing decontamination guidance in light of improving technology has been identified, as well as the need for a more risk-based approach to the requirements. This is unlikely to mean a relaxation in current standards but perhaps a more realistic approach to their application would be the best outcome for all dental professionals.

Health boards and health protection agencies take all potential breaches in infection control very seriously. If they are involved in investigating infection control errors or omissions this can result in the notification of all patients deemed to be at risk. These events are emotive and often create significant media interest which can be devastating for both patients and the practice involved.

The best approach to infection control and decontamination for all practices is to ensure the whole dental team are fully aware of their responsibilities and the potential pitfalls if it all goes wrong. The need for policies, training and evidence of consistent good practice cannot be emphasised strongly enough.

Irene Black is a general dental practitioner and assistant director (decontamination) with NHS Education for Scotland (NES)