An Audit ofCross Infection Control Procedures    in General Dental Practice   Project Coordinator: Dr John Booth, GDP     ...
ContentsAbstract                                       1Introduction                                   2Aims              ...
AbstractThis audit aimed to establish the cross infection control procedures currently being carriedout within Lothian gen...
The importance of protecting patients and staff from cross infection within the dentalpractice should be obvious to all me...
To assess cross infection control procedures of general dental practitioners and dentalnurses in Lothian.The British Denta...
Questionnaires were sent to all general dental practitioners and their dental nurses at allpractices in Lothian, however, ...
“It is imperative that all staff are vaccinated against the commonillnesses.Good quality non-sterile medical gloves should...
group than there are amongst the nurses. School rubella vaccination programmes areprimarily aimed at females and this prob...
100              80 percentage              60                                                   48.5               Dentis...
64.4% of dentists and 60.8% of nurses always wore surgical-type masks whilst carryingout any procedure which might have in...
56.4% of dentists and 56.9% of nurses always provided eye protection for patients whilstcarrying out procedures which migh...
Cleaning and Sterilisation of InstrumentsCriteriaThe BDA Advice Sheet states that:“It is recommended that all instruments ...
67.1% of dentists and 80.8% of nurses reported that manual scrubbing was always usedto clean handpieces before sterilisati...
When cross referenced against personal details it was found that those who had been anurse for more than 5 years were more...
Cleaning and Disinfecting SurfacesCriteriaBDA Advice Sheet A12 states that:“Effective cleaning and disinfecting are greatl...
92.6% of dentists and 93.8% of nurses reported that contaminated work surfaces werecleaned and disinfected after each pati...
91.9% of dentists and 91.5% of nurses reported that a tray system was always used todeliver instruments to the dental unit...
Only 53% of dentists and 59.2% of nurses reported that impressions and appliances werealways cleaned and disinfected befor...
Clinical Waste DisposalCriteriaThe BDA Advice Sheet states that:“All waste in the practice should be segregated into clini...
99.3% of dentists and 99.2% of nurses stated that used sharps were always disposed ofin a rigid sealable container.       ...
When cross-referenced against personal details it was found that practice owners weremore likely to always store clinical ...
General Comments36.5% of dentists and 20.2% of nurses reported that they had difficulty in followingrecommended cross infe...
DiscussionAnalysis of the completed questionnaires has thrown up some significant points whichhave been highlighted where ...
relate the numbers of respondents who indicated that further training or revised guidelineswould be useful, then there wou...
•   Practices should update their knowledge by regularly reviewing guidelines on cross    infection control.•   Individual...
I am indebted to Elaine Wilson of the Clinical Audit Team for her invaluable assistancethroughout the audit and to all of ...
2      Bentley EM, Sarll DW. Improvements in cross-infection control in general dental       practice. Br Dent J 1995; 179...
For further information or, copies of the report, please contact              Primary Care Clinical Audit Team            ...
An Audit of Cross Infection Control Procedures in General ...
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An Audit of Cross Infection Control Procedures in General ...

  1. 1. An Audit ofCross Infection Control Procedures in General Dental Practice Project Coordinator: Dr John Booth, GDP August 1999 The Primary Care Clinical Audit Team Primary Care Development Stevenson House 555 Gorgie Road Edinburgh EH11 3LG Tel: 0131 537 8562 Fax: 0131 537 8502
  2. 2. ContentsAbstract 1Introduction 2Aims 3Methodology 3Results 4 Personal Details 4 Personal Protection 5 Cleaning & Sterilisation of Instruments 10 Cleaning & Disinfecting Surfaces 13 Clinical Waste Disposal 17 General Comments 20Discussion 21Recommendations 23Acknowledgements 24References 25
  3. 3. AbstractThis audit aimed to establish the cross infection control procedures currently being carriedout within Lothian general dental practices related to the BDA guidelines issued in AdviceSheet A12. Nurses and general practitioners in participating practices were asked tocomplete confidential questionnaires based around a core of the BDA guidelines. Theresponse rate was 43%. The results show that most dentists and nurses follow most ofthe recommended guidelines most of the time. However, cross infection control could befurther improved by some simple measures e.g. reviewing the use of protective eyewearfor all team members and patients during aerosol-producing procedures. The audit alsohighlighted the need for standardised guidelines and emphasised the need for suchguidelines to be adopted and “owned” by the chairside team as a whole. 41.6% ofdentists and 20% of nurses identified the need for further training and 21.5% of dentistsand nurses indicated that revision of the guidelines would reduce difficulties in applyingrecommended guidelines in the surgery. Introduction27/09/99 1
  4. 4. The importance of protecting patients and staff from cross infection within the dentalpractice should be obvious to all members of the dental team. The last decade has seencross infection control guidelines change in response to our increased knowledge ofpotential pathogens and their routes of transmission. Current recommendations indicatethat we should take “universal precautions” so that all of our patients are treated in thesame way under the assumption that any patient could be a source of infection andconversely that we have the potential to infect any of our patients. Consequently, suchguidelines need to be reviewed regularly so that the dental team and the cross infectioncontrol procedures that they practice are kept up to date.This audit was devised to assess those cross infection control procedures currently beingcarried out routinely in dental practices within Lothian. However, it was also hoped thatparticipation in the audit would prove useful to individual practices by leading the dentalteam to scrutinise their own cross infection control procedures.The questionnaire was compiled using the BDA guidelines on cross infection control1 as abenchmark but rather than produce questions covering every aspect of those guidelines,focussed on the main areas covered within each section. It was hoped that a more user-friendly document might then be produced which would in turn lead to a higher responserate from individual practices.In most practices many cross infection control procedures are delegated to the dentalnurse and so, given this team approach, a questionnaire was sent to both dentist andnurse individually. In this way it was hoped to gain a greater insight into any differenceswhich might exist between different members of the chairside team. Again, this wouldallow practices greater scope for scrutinising their own procedures.In a similar vein the questionnaire asked respondents for some personal details to attemptto determine any correlation between these and the procedures being carried out. Wheresignificant correlations did occur, these have been detailed, where appropriate, within theresults section.Unfortunately, the response rate to the questionnaire was low but the results do providean overview of the cross infection control procedures currently being carried out withingeneral dental practices in Lothian and will I hope prove useful to all of those who tookpart in the audit. Aims27/09/99 2
  5. 5. To assess cross infection control procedures of general dental practitioners and dentalnurses in Lothian.The British Dental Association Advice Sheet on Infection Control in Dentistry1 was used asa standard against which to compare practice. MethodologyA confidential coded questionnaire was sent to all general dental practitioners in Lothianand the dental nurse who worked most closely with them. Both the general dentalpractitioner and dental nurse were provided with their own return envelope in the hopethat this would encourage dental nurses to provide more open responses.The questionnaire was based on the British Dental Association Advice Sheet andconsisted of 6 categories: personal details, personal protection, cleaning and sterilisationof instruments, cleaning and disinfecting surfaces, clinical waste disposal and generalcomments.Statistical analysis was undertaken using SPSS. Each variable was analysed for eachgroup and differences between the groups were investigated using Pearson’s Chi squaredtest. Data from the Personal Details section was cross-referenced to cross infectioncontrol practice to establish if this had any effect. ResultsOf the 756 questionnaires sent out, 10 were non-deliverable and 279 (149 dentists and130 nurses) were returned, a response rate of 37.4%.27/09/99 3
  6. 6. Questionnaires were sent to all general dental practitioners and their dental nurses at allpractices in Lothian, however, a number of dentists work at more than one practice and soreceived 2 questionnaires but only completed and returned one. If this is taken intoaccount then the response rate is 43%. Personal Details81.9% of dentists had graduated more than 5 years ago, 51.7% were the practice ownerand 63.1% had worked in their current practice for more than 5 years.63.1% of nurses had been a dental nurse for more than 5 years, 66.9% were qualifiednurses and 44.6% had worked in their current practice for more than 5 years.Review of BDA Advice Sheet 100 80 percentage 60 Dentist 40 35.4 31.5 29.2 Nurse 29.5 22.1 20 20 13.4 7.7 0 within last within last over 2 never year 1-2 years years agoFigure 1: Review of BDA Advice SheetCommentsA high percentage of dentists and nurses had never reviewed the BDA guidelines.However, it would be hoped that this group has reviewed an alternative source of CrossInfection Control Guidelines such as S.A.M.S. If not, then a review of the guidelineswould certainly be strongly recommended now.This is of particular importance since studies2 have shown that dentists and nurses whokeep their knowledge up to date were much more likely to follow recommendedguidelines. Personal ProtectionCriteriaThe BDA Advice Sheet states that:27/09/99 4
  7. 7. “It is imperative that all staff are vaccinated against the commonillnesses.Good quality non-sterile medical gloves should be worn for allclinical procedures and changed after every patient.Masks or visors are recommended for all operative procedures.(forboth dentists and nurses)Patients’ eyes must always be protected against possible injury.”Findings of Lothian AuditA higher proportion of dentists were vaccinated against TB, 82.6%, compared to 71.5% ofnurses (p=0.028). Only 59.1% of dentists were vaccinated against rubella compared to81.5% of nurses (p=0.000). 100 98.7 97.7 82.6 81.5 80 71.5 59.1 60 percentage Dentist Nurse 40 20 0 Hepatitis Tuberculosis RubellaFigure 2: Vaccination statusCommentsAlmost all respondents had been vaccinated against Hepatitis B, which would beexpected given that Lothian Health Board have been operating a very successfulvaccination programme in dental practices for some time now.It is hoped that the small percentage of respondents who had not been vaccinated (whopresumably may be new members of the dental team) will be soon.A large number of respondents had not been vaccinated against TB. As vaccination isusually carried out on schoolchildren it is possible that some respondents may not haverealised or have forgotten what they have been vaccinated against, whilst, others maynot have required vaccination at the time. Although TB is largely regarded as havingbeen conquered in most developed countries cases are on the rise in Eastern Europeand the developing world whilst drug resistant strains are also becoming more prevalent.It is therefore important for dentists and nurses to clarify their own TB status.Similarly a large number of respondents had not been vaccinated against rubella with asignificant difference between dentists and nurses. It may be surmised that fewerdentists have been vaccinated, as there will be many more male respondents in this27/09/99 5
  8. 8. group than there are amongst the nurses. School rubella vaccination programmes areprimarily aimed at females and this probably accounts for the significant differencebetween the groups. However, Lothian Health Board has recommended in the pastthat male dentists and nurses should consider being vaccinated against rubella to breakthe chain of infection. Males may act as a reservoir for rubella infection which may bepassed on to those females in the general population who have not yet been, or cannotbe vaccinated against rubella.Individual dentists and nurses should therefore review their vaccination status in light ofthis information.96.6% of dentists and 88.5% of nurses always wore gloves when treating patients(p=0.049). 100 96.6 88.5 80 percentage 60 Dentist Nurse 40 20 9.2 3.4 1.5 0.8 0 Always Sometimes Never MissingFigure 3: Gloves worn when treating patients72.5% of dentists and 70.8% of nurses always wore a new pair of gloves for each patientbeing treated. 100 80 72.5 70.8 60 percentage Dentist Nurse 40 25.523.8 20 3.1 2.3 2 0 Always Sometimes Never MissingFigure 4: New Gloves are worn for each patient32.2% of dentists and 33.1% of nurses always washed/disinfected their gloves betweeneach patient.27/09/99 6
  9. 9. 100 80 percentage 60 48.5 Dentist 43 Nurse 40 32.2 33.1 20 14.1 12.3 10.7 6.2 0 Always Sometimes Never MissingFigure 5: Gloves washed between each patientThe guidelines state that a new pair of gloves should always be worn for each patient.Washing gloves between each patient is no longer regarded as satisfactory. Figure 5highlights a “discrepancy” in the results as 72.5% of dentists and 70.8% of nurses alwayswore new gloves for each patient being treated, yet, 42.9% of dentists and 39.3% ofnurses always or sometimes washed gloves between patients.93.3% of dentists and 94.6% of nurses always discarded and replaced torn, cut orpunctured gloves immediately. 100 93.3 94.6 80 percentage 60 Dentist Nurse 40 20 6 0.7 1.5 2.3 1.5 0 Always Sometimes Never MissingFigure 6: Torn, cut or punctured gloves were immediately discarded and replacedWhen cross-referenced with Personal Details it was found that graduation of less than 5years ago (p=0.011), not being a practice owner (p=0.009) and having been employed forless than 5 years (p=0.007) all had an effect on glove wearing practice in that thesedentists were more likely to always wear a new pair of gloves for each patient.27/09/99 7
  10. 10. 64.4% of dentists and 60.8% of nurses always wore surgical-type masks whilst carryingout any procedure which might have involved a risk of splash or aerosol generation. 100 80 64.4 60.8 60 percentage Dentist Nurse 40 24.8 23.1 20 15.4 10.7 0.8 0 Always Sometimes Never MissingFigure 7: Surgical-type masks were wornOf those nurses who responded to this question (n=128), 67.8% of qualified nursesalways wore a mask compared to 48.8% of unqualified nurses (p=0.024).81.9% of dentists and 60.8% of nurses always wore eye protection whilst carrying out anyprocedure which might have involved a risk of splash or aerosol generation (p=0.001). 100 81.9 80 60.8 60 percentage Dentist Nurse 40 21.5 20 16.9 12.1 6 0.8 0 Always Sometimes Never MissingFigure 8: Eye protection was worn27/09/99 8
  11. 11. 56.4% of dentists and 56.9% of nurses always provided eye protection for patients whilstcarrying out procedures which might have involved a risk of splash or aerosol generation. 100 80 60 56.4 56.9 percentage Dentist Nurse 40 32.2 26.9 20 15.4 11.4 0.8 0 Always Sometimes Never MissingFigure 9: Eye protection provided for patientsCommentsA large number of respondents only wore masks sometimes or not at all. Whilst nursesand patients used eye protection far less frequently than dentists despite being just asvulnerable to eye contamination or injury during splash producing procedures.27/09/99 9
  12. 12. Cleaning and Sterilisation of InstrumentsCriteriaThe BDA Advice Sheet states that:“It is recommended that all instruments contaminated with oral andother body fluids are sterilised. There are three stages to thesterilisation process: pre-sterilisation cleaning, sterilisationand aseptic storage.(i) Pre-sterilisation cleaning: Used instruments are often contaminated with blood and saliva and must be completely cleaned, by hand or using an ultrasonic bath before sterilisation. It is important that thick household-type gloves are worn when cleaning instruments to protect against accidental injury….(ii) The method of choice for the sterilisation of all dental instruments is autoclaving.”(all that are autoclavable)Findings of Lothian Audit19.5% of dentists and 26.2% of nurses reported that thick gloves were always worn whencleaning used instruments by hand. 100 80 60 percentage Dentist 46.3 48.5 Nurse 40 31.5 26.2 23.8 19.5 20 2.7 1.5 0 Always Sometimes Never MissingFigure 10: Thick gloves were worn when cleaning used instruments27/09/99 10
  13. 13. 67.1% of dentists and 80.8% of nurses reported that manual scrubbing was always usedto clean handpieces before sterilisation (p=0.035). 100% 8.7 4.6 6.2 9.2 9.4 80% 21.5 6.2 9.4 percentage 60% Missing 85.9 89.2 79.7 84.6 67.1 80.8 57 68.5 Never 40% Sometimes 20% Always 0% Dentist Dentist Dentist Nurse Nurse Nurse Nurse Dentist Hand instruments Burs Handpieces 3-in-1 TipsFigure 11: Manual scrubbing used to clean instruments before sterilisation 100% 80% 36.2 38.5 43 43.6 percentage 60% 47 43.1 Missing 26.2 Never 40% 28.5 30.2 25.5 11.7 Sometimes 18.8 Always 20% 32.3 25.4 31.5 26.8 24.2 17.4 0% Nurse Dentist Dentist Nurse Nurse Dentist Hand instruments Burs 3-in-1 TipsFigure 12: Ultrasonic bath used to clean instruments before sterilisationCommentsA large number of respondents indicated that thick gloves were only used sometimes ornever when cleaning used hand instruments. Yet, this appeared to be the preferredmethod of cleaning before sterilisation for most respondents and not the use ofultrasonic baths. Therefore, the increased use of thick protective gloves would be verydesirable.27/09/99 11
  14. 14. When cross referenced against personal details it was found that those who had been anurse for more than 5 years were more likely to always manually scrub handpieces beforesterilisation, 87.8% compared to 68.8 % of nurses with less than 5 years experience(p=0.022). However, the results also showed that unqualified nurses were more likely toalways manually scrub handpieces before sterilisation 95% compared to 76.7% ofqualified nurses (p=0.042).Initially it was thought that this difference could be explained by the fact that nurses withgreater than 5 years experience were more likely to be unqualified compared to nurseswith less than 5 years experience, however, the data did not support this. It is thereforenot possible to explain this difference from the data available. 100% 80% percentage 60% Missing 100 100 100 100 Disinfectant 40% 85.9 83.8 82.3 Autoclave 75.2 20% 0% Nurse Nurse Nurse Nurse Dentist Dentist Dentist Dentist Hand instruments Burs Handpieces 3-in-1 TipsFigure 13: Method of sterilising instrumentsCommentsThe information regarding the cleaning and sterilisation of 3-in-1 tips should be viewedin light of the fact that a number of practices used disposable tips.All hand instruments and handpieces were sterilised using an autoclave but a largenumber of respondents used disinfectant to “sterilise” burs. This can no longer beregarded as a sure method of sterilisation of burs given the length of time that they mustbe immersed in such solutions for sterilisation to occur.27/09/99 12
  15. 15. Cleaning and Disinfecting SurfacesCriteriaBDA Advice Sheet A12 states that:“Effective cleaning and disinfecting are greatly aided andsimplified by a strict system of zoning. In practice, this meansdefining the areas which may be contaminated during the operativeprocedures; only these areas need to be cleaned and disinfectedbetween patients.Protect light and chair controls (which are likely to be contaminated) withdisposable impervious coverings and change between patients. Ifdisposable coverings are not used the controls must be effectivelydecontaminated between patients.All aspirators, drains and spittoons should be cleaned after everysession with a non-foaming disinfectant.Impressions and prosthetic and orthodontic appliances must becarefully cleaned and disinfected before they are sent to alaboratory.” (While laboratory constructed impression trays, bite blocks andappliances should be disinfected when they are returned from a laboratory)Findings of Lothian Audit57.7% of dentists and 73.8% of nurses reported that work surfaces were alwaysseparated and zoned into “clean” and “contaminated” (p=0.037). 100 80 73.8 60 57.7 percentage Dentist Nurse 40 19.5 19.5 20 13.8 10 3.4 2.3 0 Always Sometimes Never MissingFigure 14: Work surfaces were zonedCommentsFewer dentists reported that areas were zoned within the surgery whereas more nursesreported that zoning was carried out. This may highlight an area where bettercommunication within the surgery would further improve the team approach to goodcross infection control.27/09/99 13
  16. 16. 92.6% of dentists and 93.8% of nurses reported that contaminated work surfaces werecleaned and disinfected after each patient. 100 92.6 93.8 80 60 percentage Dentist Nurse 40 20 7.4 6.2 0 Always Sometimes NeverFigure 15: Contaminated work surfaces were cleaned and disinfected 100% 18.5 8.7 80% 29.5 4.6 percentage 60% 72.5 Missing 58.5 Never 40% 76.2 78.5 76.9 Sometimes 66.4 20% Always 15.4 16.1 0% 2.7 6.9 Dentist Dentist Nurse Dentist Nurse Nurse Covered Wiped after Wiped at end each patient of sessionFigure 16: Covering/disinfecting of the chair, equipment handles and switchesOf those nurses who responded to this question (n=107), qualified nurses were more likelyto wipe down equipment at the end of the session, 97.1%, compared with 83.8% ofunqualified nurses (p=0.03).CommentsThe use of disposable covers did not appear to be a popular method of cross-infectioncontrol. It may be that time (and perhaps financial) factors heavily influence decisionson the use of such covers.27/09/99 14
  17. 17. 91.9% of dentists and 91.5% of nurses reported that a tray system was always used todeliver instruments to the dental unit. 100 91.9 91.5 80 60 percentage Dentist Nurse 40 20 4.7 3.8 2.7 3.8 0.7 0.8 0 Always Sometimes Never MissingFigure 17: A tray system was usedOnly 19.5% of dentists and 15.4% of nurses reported that disinfectant was always flushedthrough the aspirators and spittoons after each treatment session, and 88.6% of dentistsand 89.2% always did so at the end of the day. 100% 6.7 6.9 80% 18.8 13.8 60% Missing percentage Never 89.2 40% 46.3 88.6 Sometimes 51.5 Always 20% 19.5 15.4 0% Dentist Nurse Dentist Nurse After each At the end treatment session of the dayFigure 18: Flushing of disinfectant through aspirators and spittoonsLength of service appeared to have some effect on nurses’ practice. Of the nurses whoresponded to this question (n=105), those with less than 5 years experience were morelikely to never flush disinfectant through aspirators and spittoons at the end of eachsession, 30%, compared to 9.2% of nurses with more than 5 years experience (p=0.017).27/09/99 15
  18. 18. Only 53% of dentists and 59.2% of nurses reported that impressions and appliances werealways cleaned and disinfected before being sent to the laboratory.It is worth noting that some respondents said that they cleaned but did not disinfectimpressions and appliances. 100 80 60 59.2 percentage 53 Dentist Nurse 40 34.2 22.3 20 10.7 13.1 5.4 2 0 Always Sometimes Never MissingFigure 19: Impressions and appliances were cleaned and disinfectedCommentsMany dental labs will disinfect incoming impressions etc and will also disinfect outgoingwork. However, the onus is on individual dental practices to protect their own patientswhilst also protecting staff in dental labs, therefore, it would seem prudent to focus moreattention on this area of cross infection control. Some respondents replied that therewas some confusion regarding methods of disinfection of impressions and certainlythere were difficulties in doing so. The BDA has published a useful helpsheet on thistopic, a summary of which is included with this document.27/09/99 16
  19. 19. Clinical Waste DisposalCriteriaThe BDA Advice Sheet states that:“All waste in the practice should be segregated into clinical andnon-clinical waste. Waste contaminated with blood, saliva orother body fluids is regarded as clinical waste and must be storedin yellow containers (sacks).Sharps (needles, scalpel blades, used local anaesthetic cartridgesetc.) must be sealed in rigid puncture-proof containers beforedisposal.Clinical waste must only be collected for disposal by a registeredwaste carrier.”Findings of Lothian Audit91.9% of dentists and 91.5% of nurses stated that waste was always separated intoclinical and non-clinical waste. 100 91.9 91.5 80 60 percentage Dentist Nurse 40 20 5.4 5.4 2.7 2.3 0.8 0 Always Sometimes Never MissingFigure 20: Waste separated into clinical and non-clinical27/09/99 17
  20. 20. 99.3% of dentists and 99.2% of nurses stated that used sharps were always disposed ofin a rigid sealable container. 100 99.3 99.2 80 60 percentage Dentist Nurse 40 20 0.8 0.7 0 Always Sometimes Never MissingFigure 21: Used sharps disposed of in a rigid container94% of dentists and 94.6% of nurses reported that all other clinical waste was alwaysstored in yellow sacks. 100 94 94.6 80 60 percentage Dentist Nurse 40 20 4 3.8 2 0.8 0.8 0 Always Sometimes Never MissingFigure 22: All other clinical waste stored in yellow sacks98.7% of dentists and 97.7 % of nurses reported that used sharps and other clinical wastewas always collected separately from general refuse. 100 98.7 97.7 80 percentage 60 Dentist Nurse 40 20 0.8 0.7 0.8 0.7 0.8 0 Always Sometimes Never MissingFigure 23: Used sharps and clinical waste collected separately from general refuse27/09/99 18
  21. 21. When cross-referenced against personal details it was found that practice owners weremore likely to always store clinical waste in yellow sacks, 98.7% compared with 88.9% ofnon-practice owners (p=0.038).CommentsConcern must be raised that small numbers of respondents replied that used sharpswere only disposed of in a rigid container sometimes, that other clinical waste was onlystored in yellow sacks sometimes or never and that used sharps and clinical waste werenot collected separately from general refuse.27/09/99 19
  22. 22. General Comments36.5% of dentists and 20.2% of nurses reported that they had difficulty in followingrecommended cross infection control procedures (p=0.003).Nurses predominantly cited time constraints as the reason for this. This was also mostcommonly cited by dentists followed by financial constraints.Figure 24: Reasons for difficulties in following procedures 100 80 60 percentage Dentist 40 Nurse 28.9 20 18.5 14.1 10.8 4.7 4.6 1.5 1.5 0 Time Financial Lack of Other constraints contraints relevanceWhen asked what factors would assist in reducing difficulties in applying recommendedprocedures 41.6% of dentists said further training for the chairside team and 21.5% ofnurses said revised guidelines for cross infection procedures. 100 80 percentage 60 Dentist 41.6 40 Nurse 20 21.5 21.5 20 16.8 13.1 0 Further Revised Other training guidelinesFigure 25: Factors which would reduce difficulties27/09/99 20
  23. 23. DiscussionAnalysis of the completed questionnaires has thrown up some significant points whichhave been highlighted where appropriate in the results section. However, it would beuseful to discuss some of these points further.Firstly, there were significant differences in personal protection between dentists andnurses. Dentists were more likely to wear gloves and protective eyewear when carryingout treatment than were nurses. Whilst, most nurses cleaned “used” instruments by handrather than using an ultrasonic bath, relatively few wore thick gloves while doing so. Otherstudies2 show that these differences are not confined to Lothian and that there is ingeneral much greater scope for improvements in personal protection for dental nursesthan for dentists. Evidence has shown that dental nurse behaviour is related to that of thedentists they work with3. It would therefore seem desirable for both dentists and nurses tolook at this aspect of cross infection control together.When responses from qualified and unqualified nurses were compared there was asignificant difference between the two groups: qualified nurses were more likely to wear amask and wipe down equipment at the end of the session. Significant differences werealso recorded between nurses with over five years experience and those with lessexperience: nurses with over five years experience were more likely to scrub handpiecesbefore sterilisation and flush disinfectant through aspirators and spittoons at the end ofeach session than were less experienced nurses.This suggests that qualified and experienced nurses are more likely to follow guidelines ingeneral as has been shown in other studies4. Once again this points to the standard ofcross infection control being improved by increased or better training.Similarly it was found that younger dentists who were not a practice owner were morelikely to wear new gloves for every patient than were their older colleagues or practiceowners. This might imply that more recent graduates are more up to date with crossinfection control procedures which has again been shown in other studies 3.It is well known that knowledge, unless reinforced 5, decreases with time. In light of thisand changing cross infection control guidelines it would seem highly desirable to regularlyaudit and update individual practice cross infection control procedures. Communicationbetween dentist and nurse must be effective so that each understands their respectiverole and can carry out good cross infection control as a team. Similarly knowledge mustbe updated by reviewing guidelines regularly and through further training.However, it has been suggested by Hudson-Davies, Jones and Sarll 3, that “presentmethods of updating education and training are largely ineffective as a way of improvingcross-infection control procedures”. While they quote from another field, Sir John HarveyJones6, who notes “it is extremely difficulty to teach grown up people anything (but)...relatively easy to create conditions under which people will teach themselves....” Hecontinues “.... most people wish to improve their own performance and are eager to doso”.If we assume that respondents in this audit are interested in cross infection control, and27/09/99 21
  24. 24. relate the numbers of respondents who indicated that further training or revised guidelineswould be useful, then there would seem to be a large number of dentists and nurses whoare keen to improve their practice of cross infection control.It would also seem that further training would be most effective if it were based around thedental team as a whole rather than handed down from only one of its members. Thiswould enable team members to teach themselves and to develop their “own” guidelines tocross infection control. Recommendations27/09/99 22
  25. 25. • Practices should update their knowledge by regularly reviewing guidelines on cross infection control.• Individual dentists and nurses should review their vaccination status.• An ultrasonic bath is the favoured method of pre-sterilisation cleaning but when one is not used the wearing of thick protective gloves when cleaning instruments is recommended.• Both dentists and nurses should examine their wearing of gloves, masks and eye protection and should provide suitable eye protection for their patients.• Better communication regarding the zoning of work surfaces would further improve the team approach to good cross infection control.• Practices should refer to the fact sheet regarding the disinfection of items being sent to and received from dental laboratories.• All practices should adhere to the guidelines regarding the disposal of clinical waste.• Further training would be most effective if it were based around the dental team. Acknowledgements27/09/99 23
  26. 26. I am indebted to Elaine Wilson of the Clinical Audit Team for her invaluable assistancethroughout the audit and to all of the dentists and nurses who took the time to participate.I would also like to thank Terry Simpson for his helpful advice and comments and toacknowledge the assistance of the BDA Advisory Service in allowing reproduction of theCross Infection Control Checklist and the factsheet on the Disinfection of Impressions. References1 British Dental Association Advice Sheet A12 on Infection Control in Dentistry, 199627/09/99 24
  27. 27. 2 Bentley EM, Sarll DW. Improvements in cross-infection control in general dental practice. Br Dent J 1995; 179:19-213 Hudson-Davies SCM, Jones JH, Sarll DW. Cross-infection control in general dental practice:dentists’ behaviour compared with their knowledge and opinions. Br Dent J 1995;178:365-3694 Banks T, Jones JH, Saril DW. Dental surgery assistants’ roles in cross-infection control in general dental practice: their knowledge and use of autoclaves. Br Dent J 1994;177:378-3815 Kunzel C, Sadowsky D. Knowledge acquisition processes: dissemination of expert recommendations to general practice dentists. J Health Social Behav 1989; 30: 330-3436 Harvey Jones, Sir John. Making it happen. London: Fontana, 198827/09/99 25
  28. 28. For further information or, copies of the report, please contact Primary Care Clinical Audit Team Primary Care Development Stevenson House 555 Gorgie Road Edinburgh EH11 3LG Tel: 0131 537 8562 Fax: 0131 537 8502

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