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Training opportunities in sterilization and disinfection of patient care items and devices in dental settings

Published online by Cambridge University Press:  30 August 2023

Nabilaa Azimi,
Mounica SomaOpen the ORCID record for Mounica Soma[Opens in a new window],
Sarah E. Stream,
Muhammad Salman AshrafOpen the ORCID record for Muhammad Salman Ashraf[Opens in a new window],
Charles F. Craft,
Margaret A. Drake,
Dan K. German,
Nicolás Cortés-PenfieldOpen the ORCID record for Nicolás Cortés-Penfield[Opens in a new window],
Lacey L. Pavlovsky and
L. Kate Tyner
...Show all authors
Nabilaa Azimi
Affiliation:
University of Nebraska Medical Center, Omaha, Nebraska, USA
Mounica Soma
Affiliation:
Nebraska Infection Control Assessment and Promotion Program, Nebraska Medicine, Omaha, Nebraska, USA
Sarah E. Stream
Affiliation:
Nebraska Infection Control Assessment and Promotion Program, Nebraska Medicine, Omaha, Nebraska, USA
Muhammad Salman Ashraf
Affiliation:
Nebraska Infection Control Assessment and Promotion Program, Nebraska Medicine, Omaha, Nebraska, USADivision of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USAHealthcare-Associated Infections and Antimicrobial Resistance Program, Division of Public Health, Nebraska Department of Health and Human Services, Lincoln, Nebraska, USA
Charles F. Craft
Affiliation:
Office of Oral Health and Dentistry, Nebraska Department of Health and Human Services, Lincoln, Nebraska, USA
Margaret A. Drake
Affiliation:
Nebraska Infection Control Assessment and Promotion Program, Nebraska Medicine, Omaha, Nebraska, USA
Dan K. German
Affiliation:
Nebraska Infection Control Assessment and Promotion Program, Nebraska Medicine, Omaha, Nebraska, USA
Nicolás Cortés-Penfield
Affiliation:
Nebraska Infection Control Assessment and Promotion Program, Nebraska Medicine, Omaha, Nebraska, USADivision of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
Lacey L. Pavlovsky
Affiliation:
Nebraska Infection Control Assessment and Promotion Program, Nebraska Medicine, Omaha, Nebraska, USA
L. Kate Tyner
Affiliation:
Nebraska Infection Control Assessment and Promotion Program, Nebraska Medicine, Omaha, Nebraska, USA
Richard J. Hankins*
Affiliation:
Nebraska Infection Control Assessment and Promotion Program, Nebraska Medicine, Omaha, Nebraska, USADivision of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
*
Corresponding author: Richard Hankins; Email: Richard.hankins@unmc.edu
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Abstract

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Information

Type
Research Brief
Information
Infection Control & Hospital Epidemiology , Volume 45 , Issue 2 , February 2024, pp. 263 - 265
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Copyright
© The Author(s), 2023. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

Infection prevention and control (IPC) gaps remain in dentistry due to inadequate staff training and cross training of standardized procedures and protocols. Reference Smith, Bagg, Hurrell and McHugh1,Reference Weber and Rutala2 The literature emphasizes the need for education and training in the sterilization process, sterilizers, and the benefits of competency evaluations. Reference Smith, Bagg, Hurrell and McHugh1,Reference Steinkuller, Harris, Ostrosky-Zeichner and Vigil3,Reference Garcia4 From August 2018 to June 2021, the Nebraska Infection Control Assessment and Promotion Program (ICAP), funded by Nebraska Department of Health and Human Services (NE DHHS) through a grant from the Centers for Disease Control and Prevention (CDC), provided voluntary consultations to dental facilities across Nebraska using a checklist adapted from the CDC “Basic Expectations of Safe Care.” 5 Our program emphasized assessments consisting of policy and practice review with staff and direct observation of clinical practice. Here, we report our findings in 3 key areas related to sterilization and disinfection of patient care items and devices: (1) staff training, (2) sterilization and disinfection processes, and (3) other best practices assessed related to instrument reprocessing.

Methods

From August 2018 to June 2021, we conducted on-site assessments of sterilization and IPC practices in 18 of Nebraska’s 817 dental facilities: 9 private practice clinics (independently owned), 7 public health clinics, and 2 other facilities. All dental facilities included in the study volunteered for the on-site assessments. Assessments included 15 questions about annual staff training on reprocessing reusable dental instruments, competency evaluations, and audit and feedback regarding adherence to reprocessing procedures. In 4 of the facilities, we also directly observed 27 specific processes, identifying opportunities for improvement in sterilization and disinfection. Nebraska ICAP staff obtained assessment responses from interviewing practice managers and infection control leads, which were analyzed using descriptive statistics. We identified questions and observations from the assessments that demonstrated nonadherence in at least 50% of the facilities.

Results

Among the 15 questions, 7 of these identified areas of nonadherence in at least 50% of the facilities. More than half (n = 9, 56.3%) of the facilities did not offer annual staff training on sterilization and disinfection practices. Most did not evaluate competency in reprocessing procedures following training (68.7%); most failed to perform routine audits for checking adherence to reprocessing procedures (81.3%); and most did not provide feedback to staff based on audit results specific to sterilization and disinfection processes (81.3%). Nonadherence in at least 50% of facilities was noted for 6 of the 27 directly observed processes. Opportunities for improvement in instrument transportation and proper immediate-use steam-sterilization processes were identified in 2 facilities where those practices were observed. Additional opportunities were identified in 2 of the 4 of facilities where sharps management, pouch- and pack-labeling protocols, and processing dental handpieces were observed. Training availability and competencies were similar between public and private facilities (Table 1).

Table 1.

Interview Responses and Direct Observations of Sterilization and Disinfection Assessments

Discussion

Our data highlight opportunities for infection control training in contemporary dental settings. A 2008 survey of 3,042 randomly sampled US dentists from various regions demonstrated that dentists who recognized the importance of infection control and had received more continuing education credits in infection control were more likely to implement CDC recommendations. Reference Cleveland, Foster and Barker6 Even when there is knowledge of infection control, lapses in practice may continue without regular retraining and competency evaluations. A survey of 765 randomly sampled dental hygienists from all 50 states indicated that they were familiar with dental infection control guidelines and considered them important but that they were frequently nonadherent to tenets of those guidelines (eg, preprocedural rinsing, handpiece reprocessing, appropriately handling contaminated instruments). Reference Garland7 These lapses can place patients and staff members at risk. Cleveland et al Reference Cleveland, Gray, Harte, Robison, Moorman and Gooch8 identified 3 reports of hepatitis B virus and hepatitis C virus transmission in dental settings, related to unsafe injection practices and failure to reprocess instruments appropriately. Indeed, according to our data, dental settings frequently do not receive adequate training on and do not follow manufacturer instructions for reprocessing. Reference Garland7

This study had several limitations. The sample size was small, and self-selection bias may have occurred due to voluntary participation from the facilities. In addition, most participating facilities (78%) were located near a metropolitan area. Other limitations in the study include that the study collected data from 2018 through 2021, and infection prevention practices could have changed in facilities after 2020 due to the coronavirus 2019 (COVID-19) pandemic. Future studies with larger sample sizes including rural dental facilities could assess regional variations in infection control and prevention (IPC) training, staff competency, and compliance in clinical practice.

Until now, data have been limited regarding US dental infection control practices, and our study provides insight into the frequent performance gaps in annual training, competency evaluations, and compliance audits. Our research stresses the importance of providing standardized training, competency evaluations, and feedback to dental staff. These processes facilitate a better understanding of sterilization and disinfection protocols, and protocols for sterilization failures. Our analysis also suggests opportunities for improvement in dental facilities’ infection control practice.

Further research is recommended to examine the efficacy of staff training, auditing, and feedback on sterilization and disinfection protocols and practices to determine the ideal approach to IPC training in dental settings. Research should also examine regional variations in IPC training and competency evaluations.

Financial support

None reported.

Conflict of interest

M.S.A. received an investigator-initiated research-study grant from Merck and Co, but he does not report any relevant conflict of interest related to this manuscript. All other authors report no conflicts of interest relevant to this article.

References

Smith, A, Bagg, J, Hurrell, D, McHugh, S. Sterilisation of re-usable instruments in general dental practice. Br Dent J 2007;203:E16–E16.CrossRefGoogle ScholarPubMed
Weber, DJ, Rutala, WA. Assessing the risk of disease transmission to patients when there is a failure to follow recommended disinfection and sterilization guidelines. Am J Infect Control 2013;41:S67–S71.CrossRefGoogle ScholarPubMed
Steinkuller, FI, Harris, K, Ostrosky-Zeichner, L, Vigil, KJ. Implementation of a successful sterilization and high-level disinfection outpatient program. Am J Infect Control 2021;49:S4–S5.CrossRefGoogle Scholar
Garcia, MJ. What is the impact of a comprehensive educational program on sterilization processes in the outpatient physician office setting. Am J Infect Control 2022;50:S15–S16.CrossRefGoogle Scholar
Summary of infection prevention practices in dental settings. Centers for Disease Control and Prevention website. https://www.cdc.gov/oralhealth/infectioncontrol/pdf/safe-care2.pdf. Published October 2016. Accessed July 15, 2023.Google Scholar
Cleveland, JL, Foster, M, Barker, L, et al. Advancing infection control in dental care settings: factors associated with dentists’ implementation of guidelines from the Centers for Disease Control and Prevention. J Am Dent Assoc 2012;143:1127–1138.CrossRefGoogle ScholarPubMed
Garland, KV. A survey of United States dental hygienists’ knowledge, attitudes, and practices with infection control guidelines. J Dent Hyg 2013;87:140–151.Google ScholarPubMed
Cleveland, JL, Gray, SK, Harte, JA, Robison, VA, Moorman, AC, Gooch, BF. Transmission of bloodborne pathogens in US dental healthcare settings: 2016 update. J Am Dent Assoc 2016;147:729–738.CrossRefGoogle Scholar
Figure 0

Table 1.Interview Responses and Direct Observations of Sterilization and Disinfection Assessments