Committing to Best Infection Control Practices

Effective implementation of infection control practices requires the necessary equipment, devices, and supplies; recognizing the risk of occupational infectious diseases; and understanding and following evidence-based approaches for healthcare worker (HCW) protection.

The most recent comprehensive series of recommendations for dentistry was published by the Centers for Disease Control and Prevention (CDC) in 2003.¹ Successful application of these infection control strategies requires a major commitment by medical and dental care providers, along with a willingness to respond to emerging, integrated, scientific information. As with any adaptation process, a number of personal factors should be considered when personnel discuss how to comply with specific regulations and recommendations (Table 1).

HCWs have substantially reduced infectious disease risks for both themselves and their patients compared to a few short decades ago. Yet, a number of surveys suggest that routine compliance needs to improve.^2-4 An often investigated area of compliance examines the potential infection control consequences when certain HCW opinions and perceptions differ from science and evidence-based recommendations. This dilemma is summarized in Table 2 (page 30).⁵

Infection control may fail if HCWs believe that they need to vary the protocol, in spite of evidence-based science. A common thread in many of the workers’ comments is the misplaced belief that each infection control procedure or product should provide an absolute safeguard against cross-infection. In fact, we need to look at each link in the chain of asepsis as providing a twofold benefit:
1. Affording a measure of effectiveness and safety as a standalone procedure, and
2. Functioning as an overlapping margin of protection with other components of the infection control program.

HAND HYGIENE

Poor hand hygiene is the principle method of transmitting pathogens in health care settings.¹ Thus, one of the highest priorities of the CDC is to improve hand asepsis to reduce health care-associated infections. The most important recent change is the recommendation to use waterless sanitizers in conjunction with hand washing throughout the day and before surgery to improve hand asepsis success.

Most HCWs have embraced this change because it is easier and faster, but important mistakes may still undermine compliance and success. Personnel should initially consider the type of procedure performed, the degree of contamination likely to occur, and the need for persistent antimicrobial activity. At the beginning of the work day, HCWs should wash their hands with either plain (liquid) soap and water or an antimicrobial hand wash agent. If there is any visible physical matter on hands, such as blood, bloody saliva, or exudate, thorough hand washing with soap and water or an antimicrobial antiseptic and rinsing are recommended to remove the contaminating bioburden. If hands are not visibly soiled, the choice of an alcohol-based hand antiseptic is also acceptable. Waterless sanitizers do not clean the hands, but are highly effective antimicrobial agents on pre-cleaned hands. Choose hand washing when removal of contamination is indicated, and use alcohol sanitizers when hands are essentially clean but antimicrobial activity is desired. This is an example of following the fundamental tenant of infection control: cleaning is the essential first step in antisepsis. HCWs who do not understand or apply this principle to hand hygiene may undermine asepsis programs. Table 3 summarizes desirable and undesirable features for both types of hand hygiene agents.7

CONDITIONS THAT INTERFERE

Personal roadblocks to effective hand hygiene are jewelry; long, false and ornamented fingernails; rough or jagged cuticles and fingernails; and dry, rough or broken skin. These conditions create complex, retentive surfaces where organisms and biological debris are more difficult to remove and likely to persist, even after repeated hand hygiene procedures.

Studies show that medical HCWs who wore artificial nails were implicated in several health care outbreaks caused by gram-negative bacteria and yeasts.^8-10 HCWs with artificial nails were more likely to contain gram-negative bacteria, like Pseudomonas aeruginosa, on their fingertips than HCW with natural nails. Artificial, long, or sharp nails may also compromise glove integrity.¹ Despite this evidence, a common opinion still expressed by some personnel is that there is no discernable risk to themselves or their patients from this practice.

THE SUCCESS OF SOAPS, SANITIZERS, AND LOTIONS

A common mistake in purchasing hand hygiene products is selecting products sold for home use rather than those with Environmental Protection Agency (EPA) approval for use in health care facilities. Professionally sold products are formulated for effectiveness against medically important organisms, frequent repeated use, and use with gloves. Performance and quality standards for other commercial products for home use may not meet professional criteria. In addition, key ingredients, such as emollients that protect skin with frequent use and make products compatible with gloves, may not be added to domestic products. Purchasing hand hygiene products that are not EPA-approved for use in clinical settings may undermine worker and patient safety by giving HCWs a false sense of the product’s capabilities or creating problems such as skin irritation that discourage use of all such products.

COMPLIANCE

Consider ease-of-use. If it’s too difficult, compliance will suffer. Placing hand hygiene stations strategically throughout the office encourages employee as well as patient use, and visibly demonstrates the office’s commitment to asepsis. Soap and alcohol sanitizer dispensers should dispense enough solution for the products to be effective.

ENVIRONMENTAL SURFACE DISINFECTION

Any re-used item or surface has the potential to transmit infectious pathogens. Microbes, such as influenza viruses, rhinoviruses, hepatitis B viruses, and Staphylococcus aureus, can survive and remain viable for hours to days or even months on operatory surfaces. Surface cleaning and disinfection are therefore fundamental tenants of professional dental practice. Since infectious materials generated in dentistry may not be visible, workers need to thoroughly clean and disinfect all potentially exposed touch or transfer surfaces every time they may become contaminated, using appropriate products and technique.

CHOOSING AN APPROPRIATE SURFACE DISINFECTANT

Selection of an environmental surface disinfectant continues to be a problem for a number of dental professionals primarily because of exaggerated claims and misleading assays reported in the literature. This may be compounded when patient care providers are not aware of guidelines that can assist in selection of suitable disinfectants. This situation can be addressed by initially comparing products under consideration with published criteria for an ideal agent (Table 4).¹¹ All involved in the decision must be aware, however, that no available product fulfills all of the criteria. In addition, products must be used as directed to be effective. Workers must understand what products do and what their limitations are to use them effectively. Opinions, misconceptions, and habits can motivate HCWs to use disinfection products incorrectly.

RELIABILITY OF DISINFECTANTS

Many workers are unaware of the distinction between cleaning and disinfection, yet commonly used room disinfectant product labels state “for use on precleaned, hard, nonporous surfaces.” To insure that disinfection is effective, the surface should be sprayed or wiped once to clean, then again to disinfect, even if the surface is not visibly dirty. This protocol is designed to begin the disinfection process by reducing organic materials including pathogens and by removing nonvisible residue generated during patient treatment from spray, splatter, aerosols, and contact that may interfere with disinfection.

All exposed clinical contact surfaces (surfaces likely to be touched or contaminated during patient treatment) should be cleaned and disinfected after each patient—not just those that are visibly soiled. According to the CDC, factors that determine the appropriate level of disinfection of an area or item are the potential for direct patient contact; the degree and frequency of hand contact; and the potential contamination of surface with body substances or environmental sources of microorganisms, eg, soil, dust, or water.¹

Opinion, habits, and lack of understanding may motivate HCWs to alter the sequence of steps, skip steps, or fail to use products as directed when cleaning and disinfecting surfaces. For example, disinfectants may be selected for rapid antimicrobial effectiveness, but may have inferior cleaning capabilities and require a separate, compatible cleaning product. HCWs may mistakenly use only the disinfectant without the cleaner. Selecting a single product that both cleans and disinfects effectively in two steps may avoid this problem. Some products are excellent cleaners but require extended contact time to effectively disinfect.

EFFECTIVE USE OF WIPES

The use of disposable cloths or wipes presaturated with disinfectants has increased significantly since their introduction a few years ago. They provide an effective choice for those HCW who do not like using liquid spray products for environmental surface cleaning and disinfection. Because they are saturated with chemical cleaners and disinfectants, disposable wipes decrease the amount of chemical sprayed into the environment. Unfortunately, these can be easily misused by using a single wipe to clean or disinfect large areas, instead of multiple wipes.

Results of a recent study presented at the 2008 annual meeting of the American Society for Microbiology showed that when HCWs cleaned multiple surfaces with a single wipe they risked sweeping methicillin-resistant Staphylococcus aureus (MRSA) and other pathogens around surfaces, rather than accomplishing surface cleaning. ¹² The problem appeared to be a common one, with a request made by the researchers to provide guidance to staff on how to use wipes. Performing cleaning and disinfecting steps using products effective for each step is an example of sequencing and overlapping protocol to increase the margin of safety.

SUMMARY

Compliance issues for infection control will remain as long as people can make choices about procedures and approaches. Unfortunately, by reducing the margin of overlap in recommended infection control precautions, the door may be unwittingly opened to increase infectious microbial exposures. There are acceptable, effective choices for many infection control practices that are based on epidemiological, scientific, and clinical evidence. In contrast, opinions and perceptions expressed without consideration for accumulated data and knowledge may have little or no credibility or application for provision of patient care.

REFERENCES

1. CDC. Guidelines for infection control in dental health-care settings – 2003. Morbid Mortal Wkly Rpt. 2003;51(RR-17):1-66.
2. Meengs MR, Giles BK, Chisholm CD, Cordell WH, et al. Hand washing frequency in an emergency department. Ann Emerg Med. 1994;23:1307-1312.
3. McCarthy GM, Koval JJ, MacDonald JK. Compliance with recommended infection control procedures among Canadian dentists: results of a national survey. Am J Infect Control. 1999;27:377-384.
4. Pittet D. Compliance with hand disinfection and its impact on hospital-acquired infections. J Hosp Infect. 2001;48(supplA):S40-S46.
5. Molinari JA. Infection control: perceptions and reality. Compend Contin Ed Dent. 1999;20:1096-1097.
6. Webster’s Collegiate Dictionary. 10th ed. Springfield, Mass: Merriam-Webster; 1997.
7. From Policy to Practice: OSAP’s Guide to the Guidelines. Washington, DC: Organization for Safety and Asepsis Procedures; 2004:23
8. Foca M, Jakob K, Whittier S, et al. Endemic Pseudomonas aeruginosa infection in a neonatal intensive care unit. N Engl J Med. 2000;343:695-700.
9. Moolenaar RL, Crutcher M, San Joaquin VH, et al. A prolonged outbreak of Pseudomonas aeruginosa in a neonatal intensive care unit: did staff fingernails play a role in disease transmission? Infect Control Hosp Epidemiol. 2000;21:80-85.
10. Parry MF, Grant B, Yukna M, et al. Candida osteomyelitis and diskitis after spinal surgery: an outbreak that implicates artificial nail use. Clin Infect Dis. 2001;32:353-357.
11. Molinari JA, Campbell MD, York J. Minimizing potential infections in dental practice. J Mich Dent Assoc. 1982;64:411-416.
12. Williams Gl. Can we wipe out hospital MRSA? Presented at 108th Annual Session of the American Society for Microbiology; Boston: June 2008.

From Dimensions of Dental Hygiene. September 2008; 6(9):18, 20, 22.