Management of the Office Safety Program
DEVELOPMENT OF STEP-BY-STEP PROCEDURES
EVALUATION OF THE INFECTION CONTROL PROGRAM
After completing this chapter, the student should be able to do the following:
Describe the duties of an office safety coordinator.
Describe a mechanism to evaluate the office infection control program.
List the safety documents, policy statements, and records needed by a dental office.
Design a program to evaluate infection control in the office.
Describe the general nature of a checklist that can be used to organize and assess infection control procedures in the office.
Practicing infection control procedures, managing hazardous materials and regulated medical waste, and ensuring safety against fire and storms are referred to collectively as office safety. The office safety aspects of dentistry are expanding rapidly, with new and revised regulations and recommendations appearing frequently. New asepsis or other safety products and equipment continually appear on the market, and advances in research are bringing new concepts and approaches to controlling the spread of disease agents.
Today dental practices face the challenge of finding a way to maintain and implement an effective, efficient, and affordable office safety program.
SAFETY COORDINATOR
Management of the multifaceted office safety program is facilitated if the employer identifies one person in the office to organize and supervise office safety. Such a safety coordinator works under the guidance of the employer and could be a hygienist or an assistant.
The safety coordinator must have a basic understanding of microbiology and the modes of disease spread in the office, infection control and other safety procedures, and products and equipment used with these procedures and also must know the related state and federal regulations. Extra training may be necessary at the time of initial assignment to the position, and continuing education is important so that the person can keep up with changes. The safety coordinator also should possess good written and verbal communication skills and good organizational skills and must be given time to perform the duties related to office safety.
MANAGEMENT DUTIES
Box 20-1 lists duties involved in managing the office safety program. Although the employer is responsible for all of these duties, most if not all can be delegated to the safety coordinator. Chapter 8 provides a review of steps for compliance with the Occupational Safety and Health Administration (OSHA) blood-borne pathogens standard.
The office safety coordinator and employer should develop a written personnel health program for the office workers that includes policies, procedures, and guidelines for education and training; immunizations; exposure prevention and postexposure management; medical conditions, work-related illness, and associated work restrictions; contact dermatitis and latex allergy; and maintenance of records, data management, and confidentiality.
DEVELOPMENT OF STEP-BY-STEP PROCEDURES
Establishing written step-by-step procedures much like those presented in some chapters of this book helps ensure compliance and understanding of office safety procedures to be practiced. Writing down the steps allows proper organization of the procedures, documents their existence, and enhances learning by providing material that one may review periodically.
Chapter 17 gives an example of an overall clinical asepsis protocol that describes step-by-step procedures to be performed before seating the patient, during patient care, and after patient care. The protocol presented may not apply to all practices and should be changed to relate specifically to each office.
Review Regulations and Advances
After reviewing all of the current regulations from local, state, and federal agencies, the office safety coordinator should maintain continuing education in this and related areas. The coordinator should establish contacts with or review educational material from organizations such as the American Dental Association, Organization for Safety and Asepsis Procedures, Centers for Disease Control and Prevention, American Dental Hygienists Association, American Dental Assistants Association, state dental associations, and a local school of dentistry (see Appendix A).
The Centers for Disease Control and Prevention recommendations are published in their own journal called Morbidity and Mortality Weekly Report (MMWR). Federal laws are published in the Federal Register; state laws are published in state registers. These publications are available in law schools and some public libraries, or one may obtain copies of regulations by contacting the respective federal or state agency (see Appendix A).
Enhance Communication
Office policies and procedures and details of regulations and compliance must be communicated periodically to members of the dental team during the required training on blood-borne pathogens and management of hazardous materials. Also, a key aspect of employee satisfaction is open communication among all members of the dental team. The entire team should participate in developing the total office safety program, and lines of communication should be established for constructive criticism and suggestions for improvement. An internal mechanism to resolve employee complaints is best.
WITH PATIENTS
Communication with patients regarding their safety while in the office is also important to establish trust and ensure return visits. Patients have varying degrees of knowledge about infection control and routes of disease spread. Today, patients are asking more and more questions about their safety in the office because of the news media coverage of issues in dentistry, such as the safety of amalgam fillings, the incident in Florida in which a dentist apparently infected six of his patients with human immunodeficiency virus in the late 1980s, and the concern about disease transmission through dental handpieces in the early 1990s, and more recently, contaminated dental unit water. These and other issues can erode public confidence in dentistry. Patients must be made aware of office procedures designed for their protection, many of which are conducted “behind the scenes.” Box 20-2 lists suggestions for instilling trust in patients regarding the care taken in the office for patient protection.
Maintain Office Safety Documents
Documents and records must be prepared, maintained in proper form, and made readily available to dental team members (Box 20-3).
Develop Responses to Emergencies
The office safety coordinator should develop mechanisms for rapid responses to body fluid exposures, hazardous material exposures, medical emergencies, fire, and storms. In relation to body fluid exposure, the procedure must involve a medical evaluation and follow-up as described in Chapter 8. The employer should maintain medical emergency kits, smoke alarms, and fire extinguishers; should identify an evacuation route in case of fire; and should identify procedures for protection in case of tornadoes, hurricanes, or earthquakes.
Procure and Manage Safety Products and Equipment
The employer should purchase, maintain, clean, and dispose of all products and equipment needed for infection control, management of hazardous materials, and other office safety procedures (Box 20-4). The costs of providing office safety can be difficult to recover; therefore, management of the supplies inventory, preventive maintenance of equipment, and avoiding of infection control overkill can be important.
EVALUATE PRODUCTS AND EQUIPMENT
Although adequate supplies need to be maintained, overstocking is a problem. Overstocking prolongs changing to another supply item of better quality or lower cost until current supplies have been used. The employer should evaluate products carefully and request samples before ordering and should let the entire dental team assist in the evaluation to ensure proper use when the item is purchased. The employer should make sure an item purchased will be appropriate for the desired use and should not purchase unproven substitutes or otherwise compromise appropriate quality for low cost. The employer should ensure that written and especially verbal claims about products have been documented appropriately with testing or peer-reviewed, published, scientific evaluation.
USE AND MAINTAIN PRODUCTS AND EQUIPMENT CORRECTLY
The employer should make sure that dental team members read, understand, and follow all labels and operating manuals for products and equipment. Misuse of products and equipment can lead to compromises in disease prevention or personal safety, damage to the equipment or surface related to product use, or damage to the equipment itself. Maintenance of equipment such as sterilizers, ultrasonic cleaners, vacuum traps, radiographic machines, smoke alarms, and fire extinguishers is particularly important so that they will work properly and have maximum use-life.
Periodically the employer should check and replace protective equipment such as utility gloves, eyewear, face shields, and reusable protective clothing when necessary. An inventory of all incoming chemicals ensures the availability of material safety data sheets and the presence of proper labels. The employer should ensure that disinfectants, sterilants, or other items with a specific shelf-life or use-life are replaced when indicated and should ensure that sharps containers are located where needed and that they are replaced before they overflow.
INFECTION CONTROL OVERKILL
Examples of infection control overkill that can be time-consuming and costly are routinely hand scrubbing and ultrasonically cleaning instruments, routinely cleaning and disinfecting surfaces after removal of surface covers, using more than one layer of sterilization wrap during packaging, routinely disinfecting instruments before sterilization, using thick rather than thin plastic as surface covers, using sterile gloves for routine procedures, and using special disposal mechanisms for items that are not considered as regulated medical waste.
EVALUATION OF THE INFECTION CONTROL PROGRAM
Evaluation of the office infection control program is an effective way to improve procedures so they are useful, feasible, ethical, and accurate. A successful evaluation program depends on the following:
• Developing standard operating procedures
The strategies used for the evaluation include the use of checklists to document that procedures are in place (see the following discussion), documentation that written procedures are in place and are available to all in the office, and direct observation of work activity to make sure procedures are performed correctly. One should take care about the validity of passive evaluation procedures such as second-hand verbal information obtained from staff interviews. Direct observation and documentation are usually more reliable. Six suggestions on how to determine the effectiveness of an infection control program are given in Table 20-1. The CDC has provided some examples of procedures one could evaluate in the office and how to evaluate them in Table 20-2.
TABLE 20-1
Measure the Effectiveness of an Infection Control Program
| Desired Outcomes | Examples to Measure |
| 1. Infection control procedures have been learned | Has appropriate training occurred? |
| 2. The office is assessing up-to-date infection control information | Is the office following the 2003 CDC infection control guidelines? |
| 3. Infection control procedures are being performed correctly | Does surface asepsis include precleaning prior to disinfection? |
| 4. Appropriate infection control products and equipment are being used | Is the surface disinfectant used to clean up visible blood and saliva an intermediate-level disinfectant? |
| 5. The particular infection control product or equipment is being used correctly | Does the timing of the dry heat sterilizer start after the unit has reached the sterilizing temperature? |
| 6. The office infection control program is compliant with laws and recommendations | Is the OSHA-required annual infection control training provided to all staff? |
Adapted from Miller, CH: Don’t wait, evaluate. Dent Prod Rpt 39:142, 2006.
TABLE 20-2
Examples of What to Evaluate in a Dental Office Infection Control Evaluation Program
| What to Evaluate | How to Evaluate |
| Immunizations of the office staff | Conduct an annual review of staff records to ensure up-to-date immunizations. |
| Occupational exposures to infectious materials | Report the exposures. Document and review the steps that occurred around the exposure and plan how it could be prevented in the future. |
| Postexposure management and follow-up | Ensure the postexposure management plan is understood by all office staff and that the exposure evaluation procedures are available at all times. |
| Hand hygiene procedures | Observe and document circumstances of appropriate and inappropriate hand hygiene. Review findings in a staff meeting. |
| Use of personnel protective barriers | Observe and document the use of barrier precautions and careful handling of sharps. Review findings in a staff meeting. |
| Monitoring the sterilization process | Compare the paper log of mechanical monitoring (time/temperature) and chemical monitoring (temperature strips) of each sterilizer load with the weekly biologic monitoring (spore testing) results. Document that appropriate procedures are in place and are performed when sterilization failure occurs. |
| Evaluating safety devices | Conduct an annual review of the exposure control plan for documentation of new developments in safety devices. |
| Microbial quality of dental unit water | Monitor the microbial content of water exiting the dental units to determine compliance with the Environmental Protection Agency drinking water standard of no more than 500 CFU/mL of heterotrophic bacteria. |
Preparation of standard operating procedures will document the correct way of doing something. Direct observation of work activity ensures that the dental team understands how properly to perform procedures and use equipment. Problems with compliance may indicate that further training is needed. The person performing a procedure may use a checklist when direct observation is not possible.
CHECKLIST FOR THE INFECTION CONTROL PROGRAM
One can use the following checklist to organize, review, and update an infection control program for the office.
Exposure Control Plan and Other Written Documents
1. A written exposure control plan (as required by OSHA) for the office is available and contains the following:
b. The schedule and method of implementation of the methods of compliance, the hepatitis vaccination, the postexposure medical evaluation and follow-up, the communication of biohazards, and the record keeping related to the OSHA blood-borne pathogens standard
c. The procedures for evaluating the circumstances surrounding an exposure incident
d. The methods used and the results of the evaluation of new safety devices for use in the office
2. The exposure control plan is updated at least annually and whenever changes occur in the laws, in modes of exposure, or in procedures, equipment, or supplies used to prevent the spread of disease agents.
3. A copy of the exposure control plan is made available to all involved employees.
4. A written personnel health program (recommended by the Centers for Disease Control and Prevention) for the office staff exists that includes policies, procedures, and guidelines for education and training; immunizations; exposure prevention and postexposure management; medical conditions, work-related illness, and associated work restrictions; contact dermatitis and latex hypersensitivity; and maintenance of records, data management, and confidentiality.
5. A written tuberculosis infection control plan based on Centers for Disease Control and Prevention recommendations is available to all office staff and is followed.
6. The office infection control program is evaluated routinely.
Training of the Office Staff
1. The OSHA-required training of appropriate office staff is provided on initial employment at no cost to the staff at a reasonable time and place by a person knowledgeable about the subjects and about the dental office environment. It includes the following:
a. A description of the cause, symptoms, epidemiology, spread, and prevention of blood-borne diseases and tuberculosis
b. Details of the exposure control plan for the office
c. The selection, use, limitations, and management of equipment or supplies used to prevent spread of disease agents in the office
d. The description, safety, efficacy, administration, and benefits of hepatitis B vaccination and immunity
e. What to do if an exposure to blood or saliva occurs
f. An explanation of biohazard/color code communication used in the office
g. The availability of a copy and an explanation of the OSHA blood-borne pathogens standard and other applicable infection control laws
h. An opportunity for the trained employees to have questions immediately answered
2. Updated training of all involved office staff is given at least annually and whenever changes occur in the laws, in modes of exposure, or in procedures, equipment, or supplies used to prevent the spread of disease agents.
Hepatitis B Vaccination
1. The hepatitis B vaccination series is offered free of charge at a reasonable time and place by a licensed physician or nurse practitioner within 10 days of employment of a new person who has received proper training (see the previous discussion) about the vaccine.
2. The physician’s office involved has a copy of the OSHA blood-borne pathogens standard.
3. Prescreening for immunity to hepatitis B is not a condition of employment.
4. Employees not accepting the vaccination offer must read and sign the specific vaccination refusal statement given at the end of the OSHA blood-borne pathogens standard.
5. Written confirmations are received from the physician indicating that each involved employee has been evaluated/vaccinated.
6. Employees are tested for antibody to hepatitis B surface antigen 1 to 2 months after the third inoculation, and nonresponders are evaluated and counseled.
Postexposure Medical Evaluation and Follow-up
1. A medical evaluation and follow-up is offered free of charge at a reasonable time and place by a licensed physician or nurse practitioner to all employees who experience an occupational exposure to blood or saliva.
2. Identifiable patients involved in such exposures are requested to be evaluated for their hepatitis B and human immunodeficiency virus disease status.
3. The physician’s office involved has a copy of the OSHA blood-borne pathogens standard.
4. Written confirmations are received from the physician indicating that each involved employee has been informed of the results of the evaluations and of any medical conditions resulting from the exposure that require further evaluation or treatment.
General Methods and Aseptic Techniques
1. Standard precautions are practiced (OSHA still refers to universal precautions related to blood-borne diseases).
2. Handwashing facilities and handwashing agents are available to staff.
3. Hand hygiene is performed after removal of gloves or other protective barriers and whenever contaminated with blood, saliva, or other body fluid.
4. Eating, drinking, smoking, applying cosmetics, contacts, or lip balm are not done in areas where blood or saliva may be spread from patients.
5. Spattering or spraying of blood or saliva during patient treatment is minimized.
6. Preprocedure mouth rinsing is used.
7. Dental unit water is not used to irrigate surgical sites.
8. Dental unit water quality does not exceed 500 CFU/mL of heterotrophic bacteria.
9. Water and air are flushed for a minimum of 20 to 30 seconds between patients through all devices that are connected to the dental unit water system.
10. Antiretraction valves in the dental unit water line system (if present) are maintained properly.
11. Unit dosing is used or an aseptic retrieval system (e.g., sterile forceps) is used with every patient if a supply type item must be obtained from a bulk container.
12. Disposable items (e.g., plastic air/water syringe tips, evacuation tips, ejector tips, prophylactic cups, and prophylactic angles) are not cleaned and reused on other patients.
13. A one-way cardiopulmonary resuscitation airway or oxygen with bagging is available for staff qualified to use such devices.
14. Sterilized instrument packages are inspected just before being opened, and if the package integrity has been compromised, the instruments are not used but are repackaged and resterilized.
15. The employer identifies, evaluates, and selects devices with engineered safety features (e.g., safety syringes) as they become available on the market and at least annually. The employer enters the evaluation results and an explanation of the decision to use or not to use an evaluated device in the exposure control plan.
16. Patients are asked not to close their lips around and spit into saliva ejector tips.
17. Medication is not administered to multiple patients from a single syringe unless the syringe is sterilized between uses.
18. Single-dose vials for parenteral medications are used when possible, and multiple-dose vials are used only with appropriate aseptic techniques.
19. Single-use (disposable) devices are used for only one patient and then are discarded.
Protective Barriers
1. Appropriate gloves, mask, protective eyewear, and protective clothing are made available and are used properly when the potential exists for exposure to patient’s blood or saliva or to other contaminated surfaces or items.
2. Gloves, mask, protective eyewear, and protective clothing are removed before leaving the clinical work area and are not worn in lunch areas or out of the office.
3. Gloves, mask, protective eyewear, and protective clothing are cleaned properly, laundered, maintained, or discarded.
4. Alternative items are provided to those who may have adverse reactions to the normal barriers.
5. Sterile surgeon’s gloves are worn when performing surgical procedures.
6. Patients are screened for latex allergy.
7. Latex-free kits are available at all times.
8. Fingernails are kept short, and those who wear patient care gloves do not wear artificial nails.
9. Hand lotions are used at the end of the day to prevent skin dryness associated with hand hygiene.
10. Lotions with petrolatum or other oil emollients are not used along with latex gloves.
11. Hand-care products are stored in closed containers that are disposable or can be washed and dried before refilling.
12. Soap or lotion is not added to partially empty dispensers.
13. Contaminated, reusable, protective clothing is containerized properly and laundered in the office or by a laundry service and is not taken home by employees for laundering.
14. Proper containers/bags are used for handling contaminated laundry.
15. Contaminated laundry is identified properly by a biohazard symbol/color coding that is recognizable by the office staff.
Management of Regulated Waste
1. Proper barriers, procedures, and containers are used for safe handling of sharps, nonsharp waste, liquid waste, and human tissue, including teeth.
2. Regulated waste is identified properly by a biohazard symbol/color coding and, where required, name and address labels.
3. Recapping of needles is accomplished by a safe technique.
4. Sharps containers are located where sharps are used or may be found.
5. Sharps containers are not overfilled and are closed when being transported.
6. Tongs are available for picking up broken glass, needles, scalpel blades, and other sharps.
7. Everyone is instructed to never reach blindly to pick up or move a sharp item.
8. Specimens of human tissue, blood, saliva, or other body fluids are placed in proper containers and are identified properly by a biohazard symbol/color coding during collecting, handling, processing, storing, or transporting.
9. Regulated waste is treated properly and discarded or transported for final disposal.
Decontamination
1. Appropriate personal protective equipment is used during decontamination of instruments or operatory surfaces.
2. Equipment and instruments are decontaminated properly before servicing or shipping, and if they contain sites that are incompletely contaminated, these sites are identified before servicing or shipping.
3. Operatory or other surfaces involved in patient treatment are covered with protective barriers that are changed for every patient, or contaminated surfaces involved in patient treatment are cleaned and then disinfected between patients.
4. A written schedule of decontamination of the various work areas is maintained.
5. Reusable containers contaminated with body fluids are cleaned and disinfected after use.
6. Liquid chemical sterilants are not used for surface disinfection or as an instrument holding solution.
7. Floors, walls, and sinks are cleaned routinely, and blinds and window curtains in patient care areas are cleaned when they are visibly dusty or soiled.
8. Carpeting and cloth-covered furnishings are not used in dental operatories.
Instrument Processing
1. Containers of contaminated reusable sharps (e.g., sharp instruments) are labeled properly with a biohazard symbol/color coding, are closed on transport, and do not require one to reach inside without being able to see the sharps.
2. A central area for instrument processing is designated and divided physically or spatially by signage into the following:
3. Contaminated instruments are mechanically cleaned routinely (rather than hand scrubbed) before rinsing and packaging for sterilization.
4. Cleaned and rinsed instruments are dried and packaged before sterilization.
5. Packaging materials designed for use in sterilizers and the proper procedures for sealing packages are used.
6. Cleaned and packaged reusable instruments, handpieces, handpiece attachments, and other items are sterilized between use on patients.
7. Equipment identified by its manufacturer as a sterilizer is used for sterilization.
8. Cleaned reusable items that melt in heat sterilizers are sterilized by a low-temperature procedure (e.g., glutaraldehyde) between use on patients.
9. The use and functioning of each sterilizer is spore-tested with biologic indicators at least weekly.
10. Every package processed through the sterilizer contains an internal chemical indicator (e.g., temperature strip) and an external chemical indicator if the internal indicator cannot be seen from the outside of the package.
11. Every sterilizer run is monitored mechanically (recording of time and temperature conditions achieved).
12. Sterilized instrument packages and cassettes are allowed to dry inside the sterilizer before being handled.
13. Proper procedures are performed if sterilization monitoring detects a sterilization failure.
14. Sterilized packages are handled and stored properly and managed on a date- or event-related basis.
Laboratory Asepsis
Radiographic Asepsis
1. X-ray films or digital x-ray sensors are protected with plastic surface covers before being placed in the patient’s mouth or are rinsed and disinfected or handled aseptically after removal from the patient’s mouth.
2. The sleeves of daylight loaders do not come in contact with contaminated gloves or films.
Record Keeping
1. Medical records (name, Social Security number, written confirmation about hepatitis B evaluation for vaccination, any vaccination refusal statement, written confirmation about postexposure medical evaluation and follow-up) for each employee who may have the potential to be exposed occupationally to body fluids are maintained (to comply with OSHA and some other state requirements) in confidentiality for the duration of employment plus 30 years.
2. Records of staff training (names and job classifications of trainees, date and contents of training, name and qualifications of the trainer) are maintained (to comply with OSHA and some other state requirements) for at least 3 years.
3. Records of spore-testing results (identification of the specific sterilizer tested, dates of the testing, results, and who performed the tests) are maintained according to state and local requirements.
4. Records for the treatment or transport and final disposal of regulated waste are maintained.
Miller, C.H. Don’t wait, evaluate. Dent Prod Rpt. 2006;39:142.
Miller, C.H. Safety coordinator’s duties go beyond casual organization of safety plans. RDH. 1997;17:52.
Miller, C.H. Double check your office asepsis procedures. Dent Prod Rpt. 2003;7:94–97.
Runnells, R.R., Powell, L. Managing infection control, hazard communication, and infectious waste disposal. Dent Clin North Am. 1991;35:299–308.
Review Questions
______1. Which of the following cannot be a responsibility of the office safety coordinator?
a. review infection control laws and recommendations
b. monitor the sterilization process
______2. Which of the following is infection control overkill?
a. cleaning and then disinfecting a contaminated dental operatory surface
b. cleaning and then sterilizing hand instruments
c. hand scrubbing and then ultrasonically cleaning contaminated instruments
______3. Which of the following strategies should not be used to evaluate the office infection control program?
a. confirming the presence of written infection control policy documents
______4. The Centers for Disease Control and Prevention publishes its recommendations in the:
______5. Which of the following is known as the infection control education organization?