- Hands should be washed before and after each treatment session. Methods for this should be updated and outlined in training sessions.
- All premises are required to have a written waterline management scheme and legionella risk assessment.
- Employers must follow HSE guidlines and record a sharps injury when they are notified of it.
There are many regulations to follow in the practice, something which may leave staff confused as to which to use and when. This has led to many myths surrounding what practices should and should not do. Below are a few areas that will be explored in more detail, including what the recommended practice involves for each of them:
- hand hygiene
- legionella and its management in relation to water lines
- how to dispose of sharps in a safer method.
Myth 1 : Should hand hygiene be carried out during clinical procedures only?
Hand hygiene is an essential part of preventing infection in clinical practices and can be carried out for a number of procedures, not just clinical ones. Dental practices have a duty to themselves and their patients to ensure hand hygiene is managed in accordance with the current guidelines. These guidelines include HTM 01-05: Decontamination in primary care dental practices, The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance, and The Care Quality Commissions regulation 12 (safe care and treatment).
These advise practices to:
- Have a written practice policy and/or protocol in place.
- Use waste bins that are foot operated.
- Ensure that staff, when cleaning their hands, do not use bars of soap, scrub or use nail brushes and they do not use alcohol-impregnated wipes used for cleaning.
Hand hygiene should be carried out at the practice:
- Before and after each treatment session.
- Before and after removal of Personal Protective Equipment (PPE).
- Following manual cleaning of dental instruments.
- Before contact with instruments that have been autoclaved.
- After cleaning or maintaining decontamination devices used for dental instruments.
- After completion of decontamination work.
It is recommended that the following best practice is carried out:
- Hand-washing protocols are displayed next to hand washing facilities as a reminder to staff.
- Wall mounted liquid soap and antimicrobial hand rub dispensers are placed above or adjacent to the hand washing sink.
- Hand-washing sinks should:
- not have a plug or overflow
- have a sensor-operated or lever operated mixer tap
- not have taps that discharge directly into the drain aperture.
- There is a wall mounted paper towel dispenser.
Acceptable practice in order to meet the Essential Quality Requirements, includes:
- Training in hand hygiene as part of staff inductions. This training should be provided to all relevant staff periodically throughout the year.
- Liquid soap and antimicrobial hand rub dispensers should be sited on or adjacent to the hand washing sink.
- Normal sinks are considered as adequate, although the arrangements described under the best practice should be the practice's plan to move towards best practice under HTM01-05.
Myth 2: Legionella risk assessments and water lines should be done on new equipment only
According to HTM01-05, registered managers in dental practices have an overriding general duty of care under the Health and Safety at Work Act 1974. Part of this duty is ensuring that the water supply, storage and distributions services should comply with the best practice guidance given in the Approved Code of Practice and Guidance L8, Health and Safety Executive (ACOP L8), and HTM 04-01: The control of Legionella, hygiene, 'safe' hot water, cold water and drinking systems.
The bacteria Legionella, along with other organisms, can live in water supplies new or old. Some of these remain completely harmless, while others such as Mycobacteria Spp and Pseduomonads can cause disease, meaning water companies are required to keep them within a very strict limit of 100 Colony Forming Units (CFUs). These organisms are part of a 'biofilm' which forms rapidly in dental waterlines. The reason being that in these waterlines there is always a source of nutrients for the bacteria, and 'plasticisers' are present in the plastic tubing of the waterlines' systems. Other reasons include the fact that the ambient temperatures in surgeries can be quite high causing the water to be warm, as well as water in the systems remaining stagnant overnight and when not in use. Assessments should be done on all equipment, not just new.
Water in dental waterlines goes into patient's mouths, comes into contact with open wounds as a result of oral surgery and is swallowed by patients. There is also potential for occupational risk to the dental team from exposure to contaminated dental unit waterline aerosols. Vulnerable patients such as those suffering from chronic respiratory diseases, alcoholics, diabetics and immunocompromised patients may also be at increased risk of respiratory infection or colonisation from inhaling contaminated aerosols during dental treatment.
Mandatory requirements for the management of Legionella include the following:
- All systems require a risk assessment, however not all systems will require elaborate control measures.
- All premises are required to have a written waterline management scheme and legionella risk assessment. These schemes should be written by experienced and competent people. A competent person is someone with the necessary skills, knowledge and experience to carry out this function.
- The registered manager must ensure that all the recommendations of the written scheme and risk assessment are implemented.
- Water and air lines must be fitted with anti-retraction valves in accordance with EU regulations.
- It is mandatory to control Legionella within the dental waterline system, but there is no single system of treatment which is 100% effective.
Other Myths associated with Legionella:
Do the water lines need be maintained?
Yes, this can be done using a variety of products that are available to disinfect waterlines and they should be used daily according to manufacturer's instructions. Not all products completely remove biofilm so regular dosing according to manufacturer's instructions is required to control the bacterial count. These products can be used daily, with practice staff making up the required amount for the bottle at the side of the unit, or with a dosing device.
However, with all these products, the default position is the dental chair unit manufacturer's instructions; but there may be manufacturers who don't recommend their use.
Along with using these products, waterlines should be regularly flushed. A typical protocol for staff to follow could include:
- Running water through the water lines for 2 – 3 minutes at the start of each session and 20 – 30 seconds between every patient. This will reduce microbial accumulation. Checklists are useful to ensure compliance and provide auditable evidence.
- At the end of the day, the bottle should be disconnected, emptied, rinsed and stored inverted clean and dry overnight.
- Isolating the water supply from the mains water by using an independent bottled water system on the unit.
- Filling the bottle with freshly distilled/reverse osmosis water at the start of each day (if bottled water is used this must be from a previously unopened bottle).
- Do not fill bottles with tap water as this will introduce opportunistic respiratory bacteria into the waterline and rapidly lead to biofilm formation.
Do dental water lines require routine microbiological monitoring?
Apart from situations where there are taste or odour problems, microbiological monitoring for total viable counts is not considered to be necessary.
How often should the water be tested for Legionella?
This depends on the system in place and the outcome of the risk assessment.
How often should the temperature of the system be checked?
This depends on the outcome of the risk assessment and the components of the system.
Myth 3 : Is the use of safer sharps mandatory?
Using safer sharps in your dental practices will help you to reduce contamination. The CQC's Regulation 12 (safe care and treatment) and Regulation 15 (premises and equipment) along with the European Council Directive 2010/32/EU (the Sharps Directive) was introduced to prevent injuries and blood-borne infections in hospital and to protect healthcare workers from sharp instruments such as needles.
The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 also affects dental practices.
Professional guidelines include HSE guidelines, the European Council Directive 2010/32/EU (the Sharps Directive) and HTM 01-05: Decontamination in primary care dental practices. The requirements:
- Employers should ensure that risks from sharps injuries are adequately assessed and appropriate control measures are in place.
- There is a written practice policy/protocol in place, including a risk assessment explaining why they continue to use traditional local anaesthetic reusable syringes.
- The employer should ensure that sharps are only used where they are required.
- The employer must substitute traditional, unprotected medical sharps with a 'safer sharp' where it is reasonably practicable to do so.
- Secure containers and instructions for safe disposal of medical sharps should be placed close to the work area (but not sited on the floor).
- Regulation 7(6)(c) of COSHH requires systems to dispose of contaminated waste safely.
- Employees are trained so they know how to work safely and without risk to health with the specific sharps equipment and procedures that they will use.
- An employee who receives a sharps injury at work must notify their employer as soon as practicable. The employer must ensure they have sufficiently robust arrangements to allow employees to notify them in a timely manner, including where the employee works out-of-office hours or away from the employer's premises.
- If an employee has been injured by a sharp that has or may have exposed them to a blood-borne virus, the employer must ensure that the employee has immediate access to medical advice and has been offered post-exposure prophylaxis and any other medical treatment, as advised by a doctor. The employer must also consider whether the employee should receive counselling.
- Employers must record a sharps injury when they are notified of it, whoever provides that notification. They must also investigate the circumstances and causes of the incident, and take any action required.
- For best practice it is recommended that the single use disposable local anaesthetic delivery syringes, that incorporate a mechanism to protect against accidental injury, are used.
Acceptable practice to meet Essential Quality Requirements and the EU Directive requires practices to consider:
- Injuries can occur after a needle has been used if a healthcare worker holds the needle in one hand and attempts to place a cap on the needle with the other hand (two-handed recapping). Needles must not be recapped after use unless the employer's risk assessment has identified that recapping is itself required to prevent a risk (eg to reduce the risk of contamination of sterile preparations). In these limited cases, appropriate devices to control the risk of injury must be provided:
- Needle-blocks to remove and hold the needle cap and allow safe one-handed recapping.
- Traditional metal local anaesthetic delivery syringes in conjunction with measures such as rubber needle guards, 'jenker' needle protector, or 'safe point' automatic needle removers.
- A wall mounted flow chart within the practice detailing the process for dealing with a needle-stick injury and the contact numbers for occupational health or A&E. Members of staff will be asked to describe the process.
- If there is a sharps injury, the extent of the accident investigation should be proportionate to its potential severity.For example, if there was an injury from a clean needle as it was removed from its package, it should be sufficient to record the details and give any first aid required. Injuries involving a used needle will involve more analysis and an appropriate record should be kept of the findings of the investigation.
When there are so many aspects of so many different regulations to follow, it is always better to get your staff to help with managing certain aspects of implementing the regulations and abiding by them in practice. Having a named decontamination lead in practice can help to implement these regulations in procedures, policies and protocols. If they are set up correctly and regularly visited by all staff members, then putting the regulations and guidance into pracitce is made much easier.
- The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance http://bit.ly/1D4SXwS
- HSE guidelines on the safer use of sharps: http://bit.ly/1NpS57v
- CQC Regulation 12 (Safe care and treatment) http://bit.ly/1RS3Ir2
- CQC Regulation 15 (Premises and equipment) http://bit.ly/1UzSM0N
About the author
Dr Shilla Talati BDS graduated from Guys Hospital in 1999 and has been in general / private practice ever since. She was a partner MD of Dental Perfection in Coventry for several years where she had a special interest in the management side of her dental practice. She has run several courses for the GDP in general practice and is now involved in practice management issues including staff training, compliance monitoring, and staff motivation.