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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: Basic Guide Dentistry Series
- Sprache: Englisch
Basic Guide to INFECTION PREVENTION AND CONTROL IN DENTISTRY
A practical step-by-step guide for all members of the dental team
Thoroughly updated, this new edition ensures all members of the dental team are up to speed on the practical aspects of infection prevention and control. It provides step-by-step guidance on the safe running of a dental practice, clear and concise explanations of the key issues and concepts, an overview of the evidence base, and coverage of legal and regulatory issues about which all staff members need to be aware. With more colour photographs and illustrations than the first edition, it also includes appendices full of useful practical and clinical information, and a companion website offering helpful instructional videos and self-assessment questions.
Key topics include communicable diseases, occupational health and immunization, sharp safe working, hand hygiene, personal protective equipment, disinfection of dental instruments, surface decontamination, dental unit waterlines, clinical waste management, and pathological specimen handling.
An indispensable working resource for the busy dental practice, Basic Guide to Infection Prevention and Control in Dentistry, 2nd Edition is also an excellent primer for dental students.
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Veröffentlichungsjahr: 2017
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Table of Contents
Cover
Title Page
Foreword
Preface
Acknowledgements
About the companion website
Chapter 1: Essentials of infection control
WHY DO WE NEED INFECTION CONTROL IN DENTISTRY?
RELATIVE RISK AND RISK PERCEPTION
RISK ASSESSMENT AND THE MANAGEMENT DECISION‐MAKING PROCESS
HOW TO PERFORM A RISK ASSESSMENT IN A DENTAL PRACTICE
HIERARCHY OF RISK MANAGEMENT CONTROL
INFECTION CONTROL AND THE LAW
LEGAL ACTS UNDER WHICH DENTAL PRACTICE IS CONDUCTED
PUBLISHED STANDARDS AND GUIDANCE
TEAM APPROACH TO PREVENTION OF INFECTION
REFERENCES AND WEBSITES
Chapter 2: Communicable diseases in the dental surgery
HOW INFECTIONS ARE SPREAD
RESERVOIRS AND SOURCES OF INFECTION
INFECTIOUS DISEASES BY ROUTE OF INFECTION IN DENTISTRY
INFECTIOUS DISEASE BY ROUTE OF TRANSMISSION IN THE DENTAL SURGERY
EMERGING AND RE‐EMERGING PATHOGENS
REFERENCES AND WEBSITES
Chapter 3: Occupational health and immunization
OCCUPATIONAL HEALTH HAZARDS
BUILDING A CULTURE OF SAFETY
ORGANIZING STAFF HEALTH IN A DENTAL PRACTICE
IMMUNIZATION REQUIREMENTS FOR DENTISTRY
PROTECTING WOMEN OF CHILDBEARING AGE
OCCUPATIONAL VACCINES TO PROTECT AGAINST HEPATITIS AND TB
HEALTH CHECKS AND THE CONSEQUENCES OFBLOOD‐BORNE VIRUS INFECTION
HEALTH CLEARANCE
DUTY OF CARE TO PATIENTS
REFERENCES AND WEBSITES
Chapter 4: Sharp safe working in the dental surgery
WHY SHARPS PREVENTION IS IMPORTANT
WHEN DO SHARPS INJURIES OCCUR?
PREVENTABLE SHARPS INJURIES
HOW TO AVOID A SHARPS INJURY
MANAGING SHARPS INJURIES AND SPLASHES
OCCUPATIONAL HEALTH RISK ASSESSMENT FOR BBV EXPOSURE
MANAGEMENT OF HEPATITIS C EXPOSURES
POSTEXPOSURE PROPHYLAXIS FOR HIV AND HEPATITIS B
RECORDING OF SHARPS INJURIES
CLINICAL GOVERNANCE AND ACCIDENT RISK ASSESSMENT
REFERENCES AND WEBSITES
Chapter 5: Hand hygiene
HANDS AS A SOURCE OF INFECTION
HANDS AS A SOURCE OF HOSPITAL‐ACQUIREDINFECTION
HAND HYGIENE AND TEAMWORKING
HAND HYGIENE TECHNIQUE
HAND CARE AND PREVENTION OF DERMATITIS
REFERENCES AND WEBSITES
Chapter 6: Personal protection for prevention of cross‐infection
WHY WE WEAR PERSONAL PROTECTIVE EQUIPMENT
THE ROLE OF GLOVES
CHOOSING A SUITABLE GLOVE FOR THE TASK
MANAGING AN ALLERGY TO NRL GLOVES
MANAGING LATEX ALLERGIES IN PATIENTS
MASKS AND WHEN TO USE THEM
PROTECTIVE EYEWEAR AND VISORS
PROTECTION DURING CARDIOPULMONARY RESUSCITATION
TUNICS AND UNIFORMS
PROTECTIVE BARRIERS – PLASTIC APRONS AND SURGICAL GOWNS
REFERENCES AND WEBSITES
Chapter 7: Sterilization and disinfection of dental instruments
DECONTAMINATION CYCLE
WHY HAS CLEANING BECOME SO IMPORTANT?
LEGAL REQUIREMENTS AND TECHNICAL STANDARDS FOR DECONTAMINATION
WHERE SHOULD INSTRUMENT DECONTAMINATION TAKE PLACE?
DESIGN OF DEDICATED DECONTAMINATION UNITS
PURCHASING OF DENTAL EQUIPMENT
CLEANING OF DENTAL INSTRUMENTS
DISINFECTION OF DENTAL HANDPIECES
MECHANICAL CLEANING WITH AN ULTRASONIC BATH
THERMAL WASHER DISINFECTORS
INSTRUMENT INSPECTION
DENTAL INSTRUMENT STERILIZATION
SUITABILITY OF STERILIZER FOR DIFFERENT LOADS
STERILIZER INSTALLATION AND VALIDATION
STEAM PURITY AND MAINTENANCE OF WATER RESERVOIR CHAMBER
HOW DO YOU KNOW YOUR STERILIZER IS WORKING?
LOADING THE STERILIZER
STORAGE OF WRAPPED AND UNWRAPPED INSTRUMENTS
SINGLE‐USE ITEMS
VARIANT CJD AND RATIONALE FOR SINGLE‐USE ITEMS
DISINFECTION OF HEAT‐SENSITIVE EQUIPMENT AND HARD SURFACES
DISINFECTION OF DENTAL IMPRESSIONS
REFERENCES AND WEBSITES
Chapter 8: Dental surgery design, surface decontamination and managing aerosols
DENTAL SURGERY DESIGN
SURVIVAL OF MICROBES ON SURGERY SURFACES
GENERAL CLEANING
SURFACE DECONTAMINATION IN THE DENTAL SURGERY
MANAGEMENT OF AEROSOLS AND SPLATTER
MANAGING LARGE BLOOD OR BODY FLUID SPILLAGES
REFERENCES AND WEBSITES
Chapter 9: Management of dental unit waterlines
WHAT ARE BIOFILMS?
RISK TO STAFF AND PATIENT HEALTH FROM DENTAL UNIT WATERLINES
METHODS TO REDUCE THE BIOFILM
CONTROL OF LEGIONELLAE IN THE DENTAL PRACTICE WATER SUPPLY
REFERENCES AND WEBSITES
Chapter 10: Healthcare waste management
LEGISLATION ON HAZARDOUS WASTE DISPOSAL
TYPES OF WASTE
WHAT IS HAZARDOUS WASTE?
CLINICAL WASTE SEGREGATION AND CLASSIFICATION
AMALGAM WASTE AND INSTALLATION OF AMALGAM SEPARATORS
MERCURY IN THE ENVIRONMENT
DISPOSAL AND HANDLING OF HAZARDOUS WASTE IN THE SURGERY
SAFE HANDLING OF CLINICAL WASTE PRIOR TO DISPOSAL
BULK STORAGE OF WASTE FOR COLLECTION
TRANSPORT OF HAZARDOUS WASTE
BENEFITS OF WASTE SEGREGATION
REFERENCES AND WEBSITES
Chapter 11: Transport and postage of diagnostic specimens, impressions and equipment for servicing and repair
LEGAL FRAMEWORK
COLLECTING SPECIMENS
TRANSPORT OF SPECIMENS TO THE LABORATORY
TRANSPORT RESTRICTIONS
FIXED PATHOLOGICAL SPECIMENS
TRANSPORTING IMPRESSIONS
EQUIPMENT TO BE SENT FOR SERVICE OR REPAIR
REFERENCES AND WEBSTES
Appendix
FURTHER SOURCES OF INFORMATION
Index
End User License Agreement
List of Tables
Chapter 03
Table 3.1 Recommended occupational immunization
Table 3.2 Classification of exposure‐prone procedures (EPPs) and non‐EPPs
Chapter 05
Table 5.1 Comparison of the properties of common hand hygiene products
Table 5.2 The three types of hand hygiene
Chapter 06
Table 6.1 Risk management hierarchy. Note PPE is at the bottom of the hierarchy
Table 6.2 Properties of clinical gloves
Table 6.3 Protection of the respiratory tract in dentistry
Chapter 07
Table 7.1 Risk assessment for decontamination of instruments and equipment
Table 7.2 Suitability of sterilizers for different types of instruments
Table 7.3 Sterilized and sterile instrument storage times
Chapter 08
Table 8.1 An example of a cleaning schedule for a dental practice
Chapter 09
Table 9.1 Examples of micro‐organisms isolated from DUWLs
Chapter 10
Table 10.1 Colour code denotes identification, segregation and method of waste disposal
Chapter 11
Table 11.1 UN categories for the transport of infectious substances
Appendix
Table A.1 Daily infection control clinical pathway.
Table A.2 Decontamination methods for specific instruments and items of dental equipment.
Table A.3 Examples of hand and hard surface disinfectants and dental unit waterline biocides.
List of Illustrations
Chapter 01
Figure 1.1 Factors influencing the development of infection control guidance in dentistry.
Figure 1.2 Grid showing how hazard severity and likelihood of occurrence are related to risk.
Chapter 02
Figure 2.1 Breaking the chain of infection.
Figure 2.2 Routes of transmission of infection in the dental surgery and how they are blocked by standard infection control precautions.
Chapter 03
Figure 3.1 How the dental team can work together to build a safety culture.
Chapter 04
Figure 4.1 Illustration to show the difficulty in removing a bent needle with a needle guard.
Figure 4.2 Safety needle with integral retractable sheath, shown in safe position; sheath is withdrawn for giving the local anaesthetic.
Figure 4.3 Disposable retractable scalpel blade shown in the open position for use and in the safety position within the integral sheath.
Figure 4.4 Aperture of the sharps receptacle shown in the open and closed positions.
Figure 4.5 Immediate first aid and further management following a percutaneous or splash incident.
Chapter 05
Figure 5.1 Microbiological hand sampling before (a) and after (b) cleaning with alcohol based hand rub.
Figure 5.2 Summary of when to clean hands. Figure a) before and figure b) after the listed activity. Illustration by Georgia Sweet.
Figure 5.3 (a) Correct dispersal of hand rub. Blue fluorescent UV alcohol‐based hand rub is applied to all parts of the hands and wrists before cleaning them. (b) Failure to distribute a green fluorescent hand rub to all parts of the hands, showing a typical pattern where the dorsum of the hands is missed. Microbes are only killed where the rub makes contact with the skin.
Figure 5.4 Commonly missed areas when cleaning hands. Hands and wrists inspected under UV light after cleaning hands with a green fluorescent UV‐sensitive alcohol‐based hand rub. Areas of hands that are missed still glow under the UV light. (a) Thumb, thumb web and cuticles. (b) Wrist.
Figure 5.5 Standard hand hygiene technique. Can be used for soap and water (as illustrated) or for applying alcohol‐based hand rubs. The initial wetting of the hands with water and the final drying of the hands is not illustrated.
Figure 5.6 Wall‐mounted alcohol‐based hand rub at the entrance to the surgery for use by patients and staff.
Figure 5.7 Wall‐mounted elbow‐operated emollient hand cream dispenser.
Chapter 06
Figure 6.1 Urticarial reaction affecting the skin of the forearm in a dentist.
Figure 6.2 A mask being fitted to the facial contours.
Figure 6.3 An FFP2 respirator mask worn with disposable safety goggles. These masks are recommended for use outside the UK.
Figure 6.4 An FFP3 respirator mask. Note the valve to make breathing and wear more comfortable and the blue nose strip to enhance fit to the facial contour.
Figure 6.5 If the healthcare worker wears spectacles then a visor or goggles should be worn over the mask.
Note
: A visor does not provide protection from respiratory aerosols, so a mask is worn under it.
Figure 6.6 Stages of aseptic glove removal to prevent contamination of the wearer’s hands and the environment.
Figure 6.7 Working bare below the elbow. The dentist is wearing a short‐sleeved, high‐neckline tunic and no watch is worn.
Figure 6.8
A
disposable over‐sleeve worn to cover the arms of the dentist during treatment.
Figure 6.9 Dentist wearing a disposable single‐use plastic apron, which is designed to protect the wearer from splatter falling on the chest and waist area of the body, when working in the seated position.
Figure 6.10 Antistatic disposable aprons in a wall‐mounted dispenser.
Figure 6.11 Single‐use disposable fluid‐repellent gown.
Chapter 07
Figure 7.1 Decontamination cycle of reusable instruments.
Figure 7.2 Basic design for a one‐room decontamination facility. A second hand basin in the clean zone is optional.
Figure 7.3 Basic design for a two‐room decontamination facility.
Figure 7.4 Demonstration of two different methods to clearly demarcate the clean and the dirty zones in a one‐room decontamination facility. (a) Different colour benchtop (white and grey) to demarcate clean and dirty zones. The junction between the zones is at the thermal washer disinfector. (b) Simple glass divider at the junction of the clean and dirty areas, which houses a two‐door thermal washer disinfector. As a method to prevent cross‐contamination, when one door is open the other is automatically locked shut.
Figure 7.5 Two‐part stable door for controlled access. The top part of the door can be opened and used as a pass‐through instrument hatch.
Figure 7.6 An example of a rigid, leak‐proof container with secure lid for instrument transportation to the decontamination suite from the dental surgery.
Figure 7.7 Demonstrating the personal protective equipment worn for instrument cleaning, including visor (or goggles), mask, plastic apron and heavy‐duty gloves.
Figure 7.8 Heat sealing machine in the clean zone to seal instrument packs either before or after sterilization. The machine is fitted with rolls of packaging of different sizes suitable for use with a range of trays sizes or for packing single instruments.
Figure 7.9 Manual cleaning of instruments. (a) Keep instruments immersed during cleaning. Note the use of a standpipe plug, which acts as an overflow as instrument washing sinks like hand basins are constructed without overflows. (b) Inspecting an instrument for residual debris or rust spots using an illuminated magnifier. Dispose of rusted instruments.
Figure 7.10 Dental handpiece cleaning and lubricating machine, which cleans up to four handpieces.
Figure 7.11 Thermal washer disinfector safe symbol on a dental handpiece.
Figure 7.12 Service oil is sprayed into the handpiece and the excess oil is allowed to drain out.
Figure 7.13 Handpiece connectors in a thermal washer disinfector. If the connector is fitted with a filter, these require regular cleaning.
Figure 7.14 The figure shows bubbles of dissolved oxygen in an ultrasonic bath. If not removed, they collect on the surface of the instruments and interfere with the cavitation action of the bath. They are removed by degassing the bath.
Figure 7.15 Protein detection test. (a) A random set of instruments and tray are swabbed and the swab is inserted into the test solution of ninhydrin. If protein is present the solution will turn blue‐purple. (b) A pass test. (c) A fail.
Figure 7.16 Foil ablation test. (a) Nine foil strips suspended from a 3 × 3 grid made from masking tape suspended across the ultrasonic bath. (b) Close‐up view demonstrating pitting and perforation of the foil strips indicating that the ultrasonic bath is working satisfactorily. (c) Foil strips mounted on a test sheet, retained as a permanent record in the machine logbook.
Figure 7.17 Scaling and staining of the interior walls and floor of a thermal washer disinfector which has been connected to an unsuitable water supply; compare the sheen on the horizontal shelf to the staining of the other surfaces.
Figure 7.18 (a) A Bowie–Dick test kit showing the yellow test sheet in the centre of the paper pack. (b) A ‘pass’ Bowie–Dick steam penetration test pasted into the sterilizer logbook. (c) A ‘failed’ Bowie–Dick test indicating a failure to remove all the air from inside the test pack and replace it with steam, as demonstrated by an incomplete colour change on the indicator sheet.
Figure 7.19 Helix test. If the vacuum pump is working correctly, air is withdrawn from the narrow‐bore tubing and replaced with steam that penetrates to the indicator test strip, which will change colour.
Figure 7.20 (a) Chemical indicator strips inserted within sterilization pouches, which are used to confirm that the pouch has been through a sterilization cycle. They help to differentiate between processed and unprocessed items, eliminating the possibility of using instruments that have not been sterilized. (b) Chemical indicators for steam and ethylene oxide sterilization printed on a self‐sealing sterilization pouch.
Figure 7.21 An example of an automated label printer linked to the sterilizer microprocessor.
Figure 7.22 International symbol designating ‘single‐use only’ on disposable tweezers. Note the pitting and striations of the metal surface of this single‐use item, which would impede any attempts at resterilization.
Chapter 08
Figure 8.1 Zones within the dental surgery where contamination is likely to occur.
Figure 8.2 Sensor‐operated tap fitted on a handwash basin; note there is no overflow.
Figure 8.3 National cleaning colour code designations by room.
Figure 8.4 Dental surgery showing high‐touch areas within the ‘dirty zone’, which require disinfection between every patient.
Figure 8.5 Covering a light handle with plastic wrapping.
Figure 8.6 Covering areas that are difficult to disinfect with plastic sleeves.
Figure 8.7 Cleaning the keyboard with a disinfectant wipe.
Figure 8.8 An example of a fully submersible washable keyboard.
Figure 8.9 Flushing of aspirator suction apparatus with detergent/disinfectant.
Figure 8.10 Aspirator removing spray generated by an air rotor.
Figure 8.11 Cleaning up chlorine‐releasing granules with a disposable cardboard trowel.
Chapter 09
Figure 9.1 Laminar flow in a dental unit waterline.
Figure 9.2 Immunofluorescent image of biofilm on dental unit waterlines.
Figure 9.3 Independent bottled water system integrated into a dental chair.
Figure 9.4 Sterile saline delivery bag.
Chapter 10
Figure 10.1 Dental waste streams
Figure 10.2 Types of waste sacks used for segregating domestic, offensive and infectious waste. (a) Clear waste sack for domestic waste. (b) Black and yellow striped waste sack for Sanpro offensive waste. (c) Orange waste sack in a leak‐proof, flame‐retardant, foot‐operated pedal bin.
Figure 10.3 High‐temperature processes.
Figure 10.4 Alternative non‐burn and low‐temperature processes.
Figure 10.5 Three steps in making a ‘swan neck’ tie to close a hazardous waste sack.
Figure 10.6 Wall‐mounted sharps receptacle (bin) for incineration. Never fill above the marked line.
Chapter 11
Figure 11.1 A specimen bottle (primary packaging) in a zip‐lock self‐sealing specimen bag (secondary packaging); note the separate outer pouch for placement of the request form.
Figure 11.2 WHO triple packaging requirements.
Guide
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Basic Guide to
The Basic Guide series addresses key topics of everyday importance to dentists, dental nurses and the rest of the dental team. The books are designed to be practical and are written in an accessible style with full colour illustrations throughout.
The books published under this series are listed below:
Basic Guide to Dental Procedures, 2nd Editionby Carole Hollins
Basic Guide to Medical Emergencies in the Dental Practice, 2nd Editionby Philip Jevon
Basic Guide to Dental Radiographyby Tim Reynolds
Basic Guide to Oral Health Education and Promotion, 2nd Editionby Simon Felton, Alison Chapman
Basic Guide to Dental Instruments, 2nd Editionby Carmen Scheller‐Sheridan
Basic Guide to Dental Sedation Nursingby Nicola Rogers
Basic Guide to Orthodontic Dental Nursingby Fiona Grist
Basic Guide to Dental Materialsby Carmen Scheller‐Sheridan
BASIC GUIDE TO INFECTION PREVENTION AND CONTROL IN DENTISTRY
Second Edition
Dr Caroline L. Pankhurst
King’s College London Dental Institute
Professor Wilson A. Coulter
University of Ulster
This edition first published 2017 © 2009, 2017 by John Wiley & Sons LtdFirst edition published by Blackwell Publishing, Ltd 2009.
Registered OfficeJohn Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
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For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley‐blackwell
The right of Dr Caroline L. Pankhurst to be identified as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.
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The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by health science practitioners for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties; including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.
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Foreword
Infection prevention and control is everybody’s business. In the current era where we confront exotic infections practically every few months, the dental practitioner, which includes each and every member of the dental team, has to be highly conversant and current with the principles and practice of infection control.
The second edition of Basic Guide to Prevention and Infection Control is a fitting and comprehensive guide to this rapidly and relentlessly evolving discipline. Both authors are doyens and acclaimed experts of their practice and they have left no stone unturned to provide the reader with a most readable, comprehensive and contemporaneous guide to the subject.
Being engaged in infection control seminars and discussions worldwide, what never ceases to amaze me is the rapidity with which new legislation on infection control evolves in various jurisdictions. This necessarily means that the practitioner has to be fully conversant with the up‐to‐the‐minute legislation, and how and why such pronouncements are made by the regulatory authorities. This book could be considered the most wide‐ranging exposition of the legislative architecture of dental infection control as currently practised in the United Kingdom. It will nevertheless serve also as a masterful guide for any reader anywhere interested in infection prevention and control.
Written in a very lucid style and a logical manner, the book covers all conceivable aspects of infection control ranging from risk assessment to managing amalgam waste. Admirably, the authors accomplish their goal essentially in 200 pages of text and figures!
I enjoyed perusing the narrative and the ample illustrations that complement the lucid text. I wish this book the success it truly deserves!
December 2016
Professor Lakshman Samaranayake DSc (hc), DDS (Glas), FRCPath, FDSRCS (Edin), FRACDS, FDSRCPS, FHKCPath, FCDSHKPast Dean of Dentistry, and Professor Emeritus, University of Hong Kong, Hong KongImmediate Past Head, School of Dentistry, and Honorary Professor of Oral Microbiomics and Infection, School of Dentistry, University of Queensland, Brisbane, AustraliaProfessor of Bioclinical Sciences, Faculty of Dentistry, Kuwait UniversityProfessor, King James IV, Royal College of Surgeons, Edinburgh (2013)Founding Editor‐in‐Chief, Journal of Investigative and Clinical Dentistry
Preface
This book was written as a practical guide to infection control and prevention in dentistry. The principles of infection control and prevention are universal, and are applicable to the same standard whatever your role in the dental team. Therefore. this book was written to be of value for those in training and all members of the dental team delivering primary and secondary dental care.
It is easy to dismiss infection prevention and control as just being about instrument sterilization and hand hygiene. In reality, infection control, if it is to be relevant and effective, has to take into account psychological attitudes, social norms and prevailing geopolitical dimensions, which is what makes the topic so interesting and dynamic. The science and evidence base underpinning infection control are also universal but standards for delivery and guidelines do vary between countries.
Since the first edition of this book, devolution within the United Kingdom has resulted in restructuring of healthcare with, in some instances, nation‐specific legislation and guidance. Reference to these variations can be found by following the hyperlinks cited on the companion website, and in the chapter on legislation. We are delighted to acknowledge that we have a community of readers around the world, so throughout the text and on the companion website we have tried to reflect both national and international approaches to health initiatives in infection control and prevention. Therefore, the reader is guided to the major international sources of advice and guidelines on both infectious diseases and infection control initiatives produced by the World Health Organization, the European Centre for Disease Prevention and Control and the Centers for Disease Control and Prevention in the USA.
Acknowledgements
We would like to thank Dr John Philpott‐Howard and Mrs Janet Davies for their most helpful comments and insights during the preparation of this book.
About the companion website
This book is accompanied by a companion website:
www.wiley.com/go/pankhurst/infection‐prevention
The website includes:
Interactive multiple choice questions (MCQs)
Further reading and useful websites
Videos
Chapter 1Essentials of infection control
WHY DO WE NEED INFECTION CONTROL IN DENTISTRY?
Dentists and other members of the dental team are exposed to a wide variety of potentially infectious micro‐organisms in their clinical working environment. The transmission of infectious agents from person to person or from inanimate objects within the clinical environment which results in infection is known as cross‐infection.
The protocols and procedures involved in the prevention and control of infection in dentistry are directed to reduce the possibility or risk of cross‐infection occurring in the dental clinic, thereby producing a safe environment for both patients and staff. In the UK, all employers have a legal obligation under the Health and Safety at Work Act 1974 to ensure that all their employees are appropriately trained and proficient in the procedures necessary for working safely. They are also required by the Control of Substances Hazardous to Health (COSHH) Regulations 2002 to review every procedure carried out by their employees which involves contact with a substance hazardous to health, including pathogenic micro‐organisms. Employers and their employees are also responsible in law to ensure that any person on the premises, including patients, contractors and visitors, is not placed at any avoidable risk, as far as is reasonably practicable.
Thus, management of the risks associated with cross‐infection is important in dentistry. We do not deal in absolutes, but our infection control measures are directed towards reducing, to an acceptable level, the probability or possibility that an infection could be transmitted. This is usually measured against the background infection rate expected in the local population, i.e. the patient, student or member of the dental team is placed at no increased risk of infection when entering the dental environment. Infection control guidance used in dentistry has developed from an assessment of the evidence base, consideration of the best clinical practice and risk assessment (Figure 1.1).
Figure 1.1 Factors influencing the development of infection control guidance in dentistry.
How we manage the prevention of cross‐infection and control the risk of spread of infection in the dental clinic is the subject of this book.
RELATIVE RISK AND RISK PERCEPTION
Risk has many definitions, and the dental profession and general public’s perception of risk can be widely divergent. This difference in interpretation can impact on how safe the general public perceives treatment in a dental clinic to be, especially following sensational media reports of so‐called ‘dirty dentists’ who are accused of failing to sterilize instruments between patients or wash their hands! For example, risks under personal control, such as driving a car, are often perceived as more acceptable than the risks of travelling by airplane or train, where control is delegated to others. Thus, the public often mistakenly perceives travelling by car to be safer than by air, even though the accident statistics do not support this perception. Unseen risks such as those associated with infection, particularly if they are associated with frightening consequences such as AIDS or MRSA, are predictably most alarming to the profession and the public. Risks can be clinical, environmental, financial, economic or political, as well as those affecting public perception and reputation of the dentist or the team.
What makes risks significant? There are a number of criteria which make risks significant and worthy of concern.
Potential for actual injury to patients or staff
Significant occupational health and safety hazard
The possibility of erosion of reputation or public confidence
Potential for litigation
Minor incidents which occur in clusters and may represent trends
Understanding what is implied by the term hazard is important when we consider the control of infection. This may be defined as a situation, or substance, including micro‐organisms, with the potential to cause harm. Risk assessment must take into account not only the likelihood or probability that a particular hazard may affect the patient or dental staff, but also the severity of the consequences.
RISK ASSESSMENT AND THE MANAGEMENT DECISION‐MAKING PROCESS
It is the role of managers of dental practices to manage risk. The Management of Health and Safety at Work Regulations 1999 require employers to carry out a risk assessment as an essential part of a risk management strategy. Infection control is an application of risk management to the dental clinical setting.
Risk management involves identification, assessment and analysis of risks and the implementation of risk control procedures designed to eliminate or reduce the risk.
Risk control in dentistry is dependent on a single‐tier approach, in which all patients are treated without discrimination as though they were potentially infectious. The practical interpretation of this concept, known as Standard Infection Control Precautions (SICPs), treats all body fluids, with the exception of sweat, as a source of infection. SICPs are a series of measures and procedures designed to prevent exposure of staff or patients to infected body fluids and secretions. Specifically, dental healthcare workers (HCWs) employ personal barriers and safe behaviours to prevent the two‐way exchange of blood, saliva and respiratory secretions between patient and operator (Box 1.1).
Box 1.1 Summary of standard infection control precautions
Use of hand hygiene
Use of gloves
Use of facial protection (surgical masks, visors or goggles)
Use of disposable aprons/gowns
Prevention and management of needlestick and sharps injuries and splash incidents
Use of respiratory hygiene and cough etiquette
Management of used surgical drapes and uniforms
Ensure safe waste management
Safe handling and decontamination of dental instruments and equipment
Decisions made within an organization, and within practice, should take into account the potential risks that could directly or indirectly affect a patient’s care. If risks are properly assessed, the process can help all healthcare professionals and organizations to set their priorities and improve decision making to reach an optimal balance of risk, benefit and cost. If dental teams systematically identify, assess, learn from and manage all risks and incidents, they will be able to reduce potential and actual risks, and identify opportunities to improve healthcare.
Risk assessment has the following benefits for delivery of dental healthcare.
Strives for the optimal balance of risk by focusing on the reduction or mitigation of risk while supporting and fostering innovation, so that greatest returns can be achieved with acceptable results, costs and risks.
Supports better decision making through a solid understanding of all risks and their likely impact.
Enables dentists to plan for uncertainty, with well‐considered contingency plans which cope with the impact of unexpected events and increase staff, patient and public confidence in the care that is delivered.
Helps the dentist comply with published standards and guidelines.
Highlights weakness and vulnerability in procedures, practices and policy changes.
HOW TO PERFORM A RISK ASSESSMENT IN A DENTAL PRACTICE
A risk assessment in dental practice involves the following steps.
Identify the hazards.
Decide who might be harmed, and how.
Evaluate the risks arising from the hazards and decide whether existing precautions are adequate or whether more needs to be done.
Record your findings, focusing on the controls.
Review your assessment periodically and revise it if necessary.
Stage 1: Identify the hazards
Divide your work into manageable categories.
Concentrate on significant hazards, which could result in serious harm or affect several people.
Ask your employees for their views; involve the whole dental team.
Separate activities into operational stages to ensure that there are no hidden hazards.
Make use of manufacturers’ datasheets to help you spot hazards and put risks in their true perspective.
Review past accidents and ill health records.
Stage 2: Who might be harmed?
Identify all members of staff at risk from the significant hazard.
Do not forget people who only come into contact with the hazard infrequently, e.g. maintenance contractors, visitors, general public and people sharing your workplace.
Highlight those persons particularly at risk who may be more vulnerable, e.g. trainees and students, pregnant women, immunocompromised patients or staff, people with disabilities, inexperienced or temporary workers and lone workers.
Stage 3: Evaluate the level of risk
The aim is to eliminate or reduce all risks to a low level.
For each significant hazard, determine whether the remaining risk, after all precautions have been taken, is high, medium or low.
Concentrate on the greatest risks first.
Examine how work is actually carried out and identify failures to follow procedures or practices.
Need to comply with legal requirements and standards.
The law says that you must do what is reasonably practical to keep your workplace safe.
A numerical evaluation of risk can be made to help prioritize the need for action and allow comparison of relative risk. Risk is equal to hazard severity multiplied by likelihood of occurrence. Assign a score of 1–5 for each, with a total value of 16–25 equating to high risk, 9–15 to medium risk and >8 to low risk (Figure 1.2).
Figure 1.2 Grid showing how hazard severity and likelihood of occurrence are related to risk.
Stage 4: Record your findings
Record the significant findings of your risk assessment and include significant hazards and important conclusions. Look at how current controls and protocols could be modified to reduce the risk further. Recording can be done simply on a spreadsheet or chart. The most important outcome of any risk assessment is the control measures so focus your efforts on making sure that the control measures the dental practice employs to manage the hazards associated with cross‐infection and other aspects of health and safety are sensible and effective.
Information to be recorded includes the following points.
Activities or work areas examined
Hazards identified
Persons exposed to the hazards
Evaluation of risks and their prioritization
Existing control measures and their effectiveness
What additional precautions are needed and who is to take action and when
Stage 5: Review your assessment
Risk assessment is a continuing process and must be kept up to date to ensure that it takes into account new activities and hazards, changes in processes, methods of work and new employees.
You must document your findings but there is no need to show how you did your assessment, provided you can show that a proper check was made and you asked who might be affected, and that you dealt with all the obvious significant hazards, taking into account the number of people who could be involved, that the precautions taken are sensible and reasonable, and that the remaining risk is low.
HIERARCHY OF RISK MANAGEMENT CONTROL
Following a risk assessment, it is necessary to implement a plan to control the observed risk. The plan of action must set out in priority order what additional controls are necessary, and aim to reduce risks to an acceptable level and comply with relevant legal requirements. You must also establish a reasonable time scale for completion and decide who is responsible for taking the necessary action.
There is a hierarchy of control options, which can be summarized as:
elimination (buy in services/goods)
substitution (use something less hazardous/risky)
enclosure (enclose to eliminate/control risks)
guarding/segregation (people/machines)
safe systems of work (reduce system to an acceptable level)
written procedures that are known and understood by those affected
adequate supervision
identification of training needs and implementation
information/instruction (signs, handouts, policies)
personal protective equipment (PPE).
These control measures can be applied as judged appropriate following the findings of the risk assessment, taking into account the legal requirements and standards, affordability and the views of the dental team.
INFECTION CONTROL AND THE LAW
Laws relating to infection control can arise from legal Acts and orders from the individual county or as European Union directives. A distinction must be made between Acts of Parliament, regulations and approved codes of practice and technical advice.
Regulations are laws, approved by the national legislative body. In the UK, the Health and Safety at Work Act 1974 and in England the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 are two primary legislative instruments that embrace all the major regulations, EU directives and technical guidance, for example COSHH, RIDDOR, HTM01‐05 (decontamination in primary dental care), HTM07‐01 (waste management), etc., that govern the way infection control and cleanliness are achieved in the dental surgery.
The Health and Safety at Work Act and general duties in the management regulations are goal setting and give employers the freedom to decide how to control risks which they identify. However, some risks are so great or the proper control measures so costly that it would not be appropriate to leave the discretion with the employer to decide what to do about regulating them. The Act and Regulations identify these risks and set out specific actions that must be taken. Often, these requirements are absolute – to do something without qualification by deciding whether it is reasonably practicable.
Approved codes of practice (ACOP) offer an interpretation of the Regulations with practical examples of good practice. ACOPs give advice on how to comply with the law by, for example, providing a guide to what is ‘reasonably practicable’. For example, if regulations use words like ‘suitable and sufficient’, an ACOP can illustrate what this requires in particular circumstances. So, if you follow the guidance in the ACOP you will be doing enough to comply with the law. ACOPs have a special legal status, which utilizes a reverse burden of proof. ‘If employers are prosecuted for a breach of health and safety law, and it is proved that they have not followed the relevant provisions of the ACOP, a court can find them at fault unless they show that they have complied with the law in some other way.’
LEGAL ACTS UNDER WHICH DENTAL PRACTICE IS CONDUCTED
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The Health and Social Care Act (HSCA) laid down the framework for provision of new organizational structures and means of commissioning and providing NHS health services in England. The Care Quality Commission (CQC) came into effect on 1 April 2009 and was established by the HSCA to regulate the quality of health and social care. Registration and inspection of dental practices are managed separately in Wales, Scotland and Northern Ireland.
For primary care dental services in England, registration with the CQC as a provider or manager was required from 1 April 2011. It is illegal and therefore a criminal offence for any primary care dental service to carry out any regulated activities unless it is registered with the CQC. Once registered, providers are monitored by the CQC and must comply with any conditions of registration. CQC inspections report on whether the dental services provided are safe, effective, caring, responsive and well led in relation to a standard set of key lines of enquiry (KLOE), which include ‘cleanliness and infection control’. The CQC benchmark for assessing cleanliness and infection control is the HSCA‐Approved Code of Practice 2015 which comprises 10 criteria for delivering infection control and prevention across healthcare, including dentistry.
Antimicrobial stewardship in dentistry
Criterion 3 of the HSCA‐ACOP relates to antimicrobial stewardship and antimicrobial prescribing. Inclusion of this criterion alongside infection control measures reflects an expedient response to the dramatic rise in antimicrobial resistance worldwide over the last decade, coupled with stagnation in the development of new classes of antibiotics to manage micro‐organisms resistant to first‐line treatments. In the UK, nearly 70% of dental prescribing of drugs is for antibiotics and research has shown that approximately 50% of dentists overuse antibiotics or are guilty of poor prescribing practices. Box 1.2 outlines the basic principles for setting up antimicrobial stewardship in dental practice.
Box 1.2 Basic principles for antibiotic stewardship in dental practice
Systems should be in place to manage and monitor the use of antimicrobials to ensure inappropriate use is minimized.
Patients should be treated promptly with the correct antibiotic, at the correct dose and duration whilst minimising toxicity (e.g. allergic reactions) and minimising conditions for the selection of resistant bacterial strains.
