Patient Safety in Practice: Tawam Hospital Dental Services

Editor’s note: Tawam Hospital Dental Services—under the direction of Tawam Hospital, a Joint Commission International–accredited organization in the eastern region of the Emirate of Abu Dhabi—has created Infection Control Guidelines to instruct staff on best practices for eliminating or mitigating infections in the course of their everyday duties. The following excerpt is from Chapter 2: Infection Control Inside the Clinic, and is presented her as direction for dental or other health care organizations seeking to better prepare frontline workers to prevent or reduce the risk of infection. JCI extends special thanks to Sumaya Al Harrasi, Section Head, Business Development, Tawam Hospital and Diane M. Chapman, Infection Control Member, Tawam Hospital, for their assistance.

Chapter 2: Infection Control Inside the Clinic
 
Part One: Before Receiving the Patient

Preparation of the Dentist and Dental Nurse

Hand Hygiene and Hand Care
Proper hand hygiene (e.g., hand washing, hand antisepsis, or surgical hand antisepsis), is the most important factor in the prevention of infection. The complete practice of this activity substantially reduces potential pathogens on the hands and is considered the single most critical measure for reducing the risk of transmitting organisms between patients and Dental Health Care Professionals (DHCP) staff.

Hand hygiene should be performed:
• Before and after treating each patient.
• After touching inanimate contaminated objects with bare hands.
• When visibly soiled.
• Before glove placement and after glove removal.
• Before leaving the clinic or dental laboratory.
• Before re-gloving after removing torn, cut or punctured gloves.

Special hand hygiene considerations include: 
• Use hand lotions to prevent skin dryness.
• Consider compatibility of hand care products with gloves (for example, mineral oils and petroleum base may cause early glove failure).
• Finger nails are to be kept short—no artificial nails.
• No jewelry should be worn (simple wedding bands only).

Personal Protective Equipment (PPE)
Personal protective equipment (PPE) is worn to protect the skin and mucous membranes of the eyes, nose, and mouth of DHCP caregivers, other staff, patients, and visitors from blood or other body fluids. The use of PPE is part of the routine dental treatment and should be worn when considered appropriate. The use of handpieces, ultrasonic scalers, and air-water syringes creates visible spray that contains droplets of water, saliva, blood, microorganisms, and other debris. This splatter travels a short distance and settles out quickly, landing on the floor, nearby operator surfaces, DHCP staff, or the patient.

PPE used at DHCP include the following (see Photo 1 below):
• Gloves
• Gowns
• Lab coats
• Masks
• Protective eyewear
• Face shields

Photo 1. DHCP Staff with PPE Source: Tawam Hospital Dental Services. Used with permission.

PPE are placed on staff in the following order, as per Centers for Disease Control and Prevention (CDC) guidelines (see Figure 1 below):

1. Gown or lab coat
2. Mask
3. Goggles or face shield
4. Gloves (wash hands first)        
                                                                      

PPE are removed in the following order:
1. Gloves
2. Goggles or face shield
3. Gown or lab coat
4. Mask (wash hands last)

Figure 1. Sequence for Donning Personal Protective Equipment   Source: Centers for Disease Control and Infection. To download this poster, click here.

Reusable PPE (e.g., face shields or goggles) should be cleaned with soap and water when contaminated, and when visibly soiled disinfect with an intermediate-level disinfectant according to manufacturer’s directions.

Gloves and masks MUST be removed before leaving the clinic. Gowns need not be removed if leaving the clinic to retrieve item/s from stock area, taking a patient to another area or if an emergency occurs requiring the help of other staff members. Gowns are not to be worn outside the clinical areas.

Protective Clothing
• Non-sterile gowns (single-use item), lab coats/jackets should be worn, unless a sterile gown (single-use item) is required to 
  protect your clothes and skin from contamination during procedures and patient care activities where it is anticipated blood or other 
  potentially infectious materials (OPIM) are likely to be generated.
• Change protective clothing if it becomes visibly soiled or penetrated by blood (as soon as feasible).
• Gowns are NOT to be worn outside the clinical area.
                    
Masks, Goggles, and Face Shields
• Wear a surgical mask and eye protection such as goggles or a face shield (see Photo 2 below) during all procedures.
• Change masks between patients or during patient treatment if the mask becomes wet

Photo 2. Care Giver with Face Shield Source: Tawam Hospital Dental Services. Used with permission.

Gloves
• All DHCP should wear clean, nonsterile gloves whenever they are working in the clinical setting, except for procedures that require sterility (e.g., implant surgery).
• Use a new pair of gloves for each patient.
• Wash hands or use alcohol-based hand rub immediately after removal of gloves.
• Remove gloves that are torn or punctured, as soon as feasible and wash and dry hands thoroughly before regloving.
• Do not wash gloves before use, disinfect, sterilize or wash gloves for re-use.
• Always have the correct glove size readily available.
 
Double Gloving
The effectiveness of wearing two pairs of gloves in preventing disease transmission has not been confirmed. Studies have demonstrated a lower frequency of inner glove perforation and visible blood on the surgeons hand when double gloves are worn.

Preparation of the Clinic Before Treatment
Protective barriers must be used to prevent cross contamination. Use barriers on any surfaces that may be faced with cross-contamination. Use surface barriers to protect clinical contact surfaces, particularly those that are difficult to clean. These barriers need to be changed between every patient regardless of how minor the treatment. Barriers should be used on the following:
• All chairs, including the dental chair and the backs of the clinician’s and assistant’s chair
• The overhead light
• The suction unit   
• Handpieces and triplex syringes
• Touch-control panel
• X-ray units, and LED monitors
• Bracket table handle

Working Surfaces
Working surfaces are to be kept free from clutter. Only essential items used for treatment of patients should be visible.

Restorative or exam trays placed on the bracket table. Making sure the tray is only opened in front of the patient, to ensure patient confidence of sterility. This also includes the un-wrapping of a large quantity of trays or any other autoclaved instruments when setting up your clinic.

Bottled materials or plastic instruments that cannot be autoclaved should be sprayed and wiped and sprayed again with a disinfectant before placing back into drawers.

Anything on the counters or mobile carts not required for the procedure should be removed to avoid contamination from aerosols that will be produced during treatment, which can stay suspended in the air up to 60 minutes or more.

Dental Chair
All surfaces of the dental chair not covered with barriers should be wiped down with the disinfectant wipes/intermediate-level disinfectant (see Photo 3).

Photo 3. Wiping the Dental Chair Source: Tawam Hospital Dental Services. Used with permission.

If barriers are used replace with a new headrest cover for each new patient (see Photo 4).         
                                                                                                  

Photo 4. Replacing the Headrest Cover Source: Tawam Hospital Dental Services. Used with permission.

Overhead Light
The overhead light handles are covered with adhesive barrier film or plastic sleeves (see Photo 5). If barrier film is not available, then ensure that the handles are wiped with disinfectant wipes/intermediate-level disinfectant between each patient. After each patient, remove the plastic barrier and place new ones.  

Photo 5. Plastic Sleeves on Overhead Light Source: Tawam Hospital Dental Services. Used with permission.

Control Panel
Touched surfaces such as the control panel and bracket handle should be covered with adhesive barrier film (see Photo 6). If barrier film is not available, then ensure that these surfaces are wiped with disinfectant wipes or intermediate-level disinfectant between each patient. After each patient, remove the barrier film, place new ones.

Photo 6. Adhesive Barrier Film on Control Panel Source: Tawam Hospital Dental Services. Used with permission.

Handpieces
A sterilized handpiece is placed for each new patient. Cover the handpiece with film or plastic sleeve until ready for use (see Photo 7).

Photo 7. Replace Handpieces and Covering Them with Plastic Sleeves Source: Tawam Hospital Dental Services. Used with permission.

Air and Water Syringes
A new tip is placed on all air and water syringes for each patient. Air and water syringes are covered with adhesive barrier film or a plastic sleeve (see Photo 8), which is changed after each patient.

Photo 8. Plastic Sleeve on Air and Water Syringe Source: Tawam Hospital Dental Services. Used with permission.

Suction Tips and Saliva Ejectors
A new disposable suction tip and saliva ejector is placed for each new patient (see Photo 9). A plastic barrier cover is placed on suction tip and saliva ejector.

Photo 9. Replacing Suction Tips Source: Tawam Hospital Dental Services. Used with permission.

Tables, Cabinets, and Hard Surfaces:
In the clinic, surfaces can become contaminated during patient care through direct spatter or DHCP’s contaminated gloved hands. These surfaces can act as reservoirs of microbial contamination. All surfaces should be wiped at the start and end of the shift with disinfectant wipes/intermediate-level disinfectant. If surfaces become contaminated with blood, the following technique should be followed:                                                                                             
• Spray and wipe visible stains with disinfectant wipes or intermediate-level disinfectant
• Wipe the surface with disposable towel or gauze
• Spray and wipe again with disinfectant wipes or intermediate-level disinfectant
• Leave to air dry

Preparation of the Patient

All patients are considered as potentially infectious. Therefore, you must always use the following standard precautions with all patients:
• Place a disposable, absorbent bib on the patient’s chest (see Photo 10).

Photo 10. Placing Disposable Bib on Patient Source: Tawam Hospital Dental Services. Used with permission.

• Open a new, sterile tray for each patient after the patient has been seated in the dental chair (see Photos 11 and 12).

Photo 11. Wrapped Sterile Tray Source: Tawam Hospital Dental Services. Used with permission.

Photo 12. Unwrapped Sterile Tray Source: Tawam Hospital Dental Services. Used with permission.

• All surfaces are covered with adhesive film barrier or plastic cover (see Photo 13).

Photo 13. Barriers and Covers on All Surfaces Source: Tawam Hospital Dental Services. Used with permission.

JCI Links   •   For more information about any Tawam Hospital, go to the organization’s Web site at http://www.tawam-hosp.gov.ae.   •   Would you like to have your organization’s patient safety initiative featured in an upcoming issue of this publication?       Send us an email with your story idea to jciezine@jcrinc.com.