Stricter standards

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Infection control and decontamination standards in particular have come to the attention of all dental professionals in recent years. It is now a process that needs to be performed to much stricter standards than previously. This has inevitably caused some upheaval in established practices but in the long term will hopefully lead to enhanced public confidence in the dental profession. This article will examine where we are today and where we may go in the near future. It will also include some of the latest news on cross infection.

Historically, the British Dental Association's (BDA's) guidance (A12) was seen as the standard for infection prevention control in dental settings across the UK. There have been a plethora of new rules and regulations since then which vary across the four nations of the UK. Officially, we are a United Kingdom; however, instrument reprocessing is subject to different rules depending on the country where the dental practice is located.

Looking at different nations of the UK gives an idea of how decontamination policy may progress in the future. The article will give a country by country breakdown.

England – HTM 01-05

Decontamination in primary dental practices (HTM 01-05) comes from the series of Department of Health documents known as HTMs (Health Technical Memorandums). There are many HTMs on issues varying from waste disposal to endoscopy. Primary dental care has its own one on decontamination in the form of HTM 01-05. As we know, all dental practices in England have to be registered with the Care Quality Commission (CQC). When inspecting practices, the CQC will assess compliance with Outcome 8 ‘Cleanliness and infection control’ by making sure the decontamination requirements set out in HTM 01-05 are being met.

HTM 01-05 can be divided into two parts - Essential quality requirements (EQR) is everything except the need for a separate decontamination room, a validated washer disinfector and separate storage of instruments (Best Practice). EQR includes everything from decontamination to hand hygiene and waste disposal. The only time when Best Practice is required is when starting a new practice from scratch and possibly when tendering for an NHS contract.

Essential quality requirements covers everything from decontamination to hand hygiene and waste disposal.

For those that choose or are required to have a separate room the following general guidance applies. It should be tailored to suit the individual practice (there are no set specifications on size requirements), be safe to work in and not too hot for staff to be comfortable. There should be clear zoning from dirty to clean with airflow moving in the opposite direction. There is still no requirement to meet best practice in England. In a survey carried out in 2010, a third of all practices were unable to install a decontamination room due to space constraints. Imposing Best Practice on England would be a considerable undertaking and a lengthy phasing in period would be required.

Recent changes to HTM 01-05

At the end of March, a 2013 edition of HTM 01-05 was published.1 Contained in it were some very welcome changes. Notably, instrument storage times were extended to one year for wrapped instruments. Unwrapped instruments can now be kept for up to a week in a non-clinical area and a day in a clinical area. There is now no difference between vacuum and non-vacuum autoclaves in terms of instrument storage times.

In terms of the Legionella risk assessment, reference to the Legionella Control Association has been amended. The guidance still requires a competent person to perform the risk assessment but now is less restrictive in terms of who can be deemed competent.

The requirement to have separate manual washing and rinsing sinks has been removed. A removable bowl can now be used for the rinsing portion of the process. However, two separate sinks remains the preferred option.

The infection control audit now needs to be done every six months rather than quarterly. It is available for download from the Infection Prevention Society (www.ips.uk.net) or can be found in PDF format on the BDA website.

Wales & Northern Ireland

Decontamination policy in Wales is also based on HTM 01-05. Like England, practices only need to meet EQR. However, the instrument storage times are different. For those using an N-type steriliser (non-vacuum), one month is the maximum storage time when wrapped after sterilisation. Where B or S type sterilisers (vacuum) are used, two months' storage is allowed. Instruments that are unwrapped should be used within a single clinical session only with any unused instruments being reprocessed.

The Health Department in Northern Ireland also adopted HTM 01-05, although the rules here are somewhat different. Best Practice has been compulsory since November 2012. That means that a separate decontamination room is required as well as a validated washer-disinfector. Instrument storage times are currently based on the previous English requirements: 21 days for an N-type steriliser and 60 days for a B or S type steriliser.

Scotland

Scotland is unique in two aspects. Firstly, it does not use HTM 01-05 at all, and secondly it does not currently have a dental healthcare regulator (though this due to change in the near future). Most practices in Scotland have a National Health Service element and are inspected in order to meet their contractual obligations. The small number of fully private practices in Scotland are not currently subject to inspection but are still expected to meet the relevant national guidelines. Guidance on decontamination and infection control in Scotland is produced by the Scottish Dental Clinical Effectiveness Programme (SDCEP) - an academic/government programme which produces guidance on a range of topics for the dental profession in Scotland. The salient points to note are that all practices have had to have a decontamination room and washer disinfector since the end of 2012. Instruments, regardless of the type of autoclave used, can be stored unwrapped indefinitely as long as they are stored in a clean, disinfected, and dry container. Much of the other guidance is similar to HTM 01-05.

Safer sharps

On a related topic, the Health and Safety Executive have published new guidelines on complying with the sharps regulations which came into force on 11 May this year. These regulations apply across the UK. Practices should have safe systems of work in place to prevent two-handed recapping of local anaesthetic needles.

Traditional, unprotected medical sharps must be substituted with a ‘safer sharp’ where it is reasonably practicable to do so. The term ‘safer sharp’ means medical sharps that incorporate features or mechanisms to prevent or minimise the risk of accidental injury. For example, a range of syringes and needles are now available with a shield or cover that slides or pivots to cover the needle after use.

If a suitable ‘safer sharp’ is not available or it is not reasonably practicable to use them, the dental professional must still ensure that safe procedures for working with and disposal of the sharp are in place.

Needles must not be recapped after use unless a risk assessment has been conducted and objectively concludes that recapping is required to control a risk – this could be a risk to the dentist, dental care professional (DCP) or patient (eg to reduce the risk of contaminating a needle used to deliver or top-up local anaesthetic). If a risk is identified, then recapping must only be done with an appropriate device to control the risk of injury (for example needle blocks or syringes with retractable sheaths).

Advice and guidelines

The BDA Health and Safety team produces an array of advice sheets and template policies related to the topics discussed above. Notably, our infection control guidelines are now available in country-specific editions. These are regularly updated and summarise the latest official guidance. For members who have opted for the Extra or Expert membership tier, one to one advice via phone and email is available. The H&S team can be contacted on 020 7563 4572 or by email at healthandsafety@bda.org.boxed-text

For further information on the BDA's course ‘Achieving high standards in infection control’, visit www.bda.org/training or call the booking hotline on 020 7563 4590. events@bda.org.