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Survey of instrument decontamination in dental surgeries located in Scottish prisons
Survey of instrument decontamination in dental surgeries located in Scottish prisons Andrew J. Smith, BDS, PhD,a Siobhan Creanor, BSc, MSc,b and David J. Hurrell, MScc Glasgow, Scotland, United Kingdom, and Plymouth, England, United Kingdom
We describe an observational study in which the policies and procedures of dental surgeries in 14 of the 15 Scottish prisons for sterilizing instruments were viewed directly by a trained surveyor. The survey found that several key elements in the decontamination cycle, ranging from procurement of devices, cleaning, sterilizing, testing, maintenance, quality management and training were deficient in a number of aspects. The use of a central sterile supply service may be a more cost effective approach for the provision of compliant instrument reprocessing facilities in the sites surveyed. Key Words: Dental; instrument cleaning; instrument sterilization; infection control; prison service. Copyright ª 2009 by the Association for Professionals in Infection Control and Epidemiology, Inc. (Am J Infect Control 2009;37:689-90.)
We describe an observational study in which the policies and procedures of dental surgeries in 14 of the 15 Scottish prisons for sterilizing instruments were viewed directly by a trained surveyor. The survey found that several key elements in the decontamination cycle including procurement of devices, cleaning, sterilizing, testing, maintenance, quality management, and training were deficient in a number of aspects. The use of a central sterile supply service may be a more cost-effective approach for the provision of compliant instrument reprocessing facilities in the sites surveyed. The effective cleaning and sterilization of dental instruments is a core component of standard infection control precautions, previously referred to as Universal Precautions.1 The cleaning and sterilization of dental instruments comprises a number of interlinked processes with several critical control points.2 The reprocessing of instruments in both acute and primary care facilities has been shown to be suboptimal in many cases.2,3 From the Infection Research Group, University of Glasgow Dental School, Glasgow Dental Hospital and School, Faculty of Medicine, Glasgow, Scotlanda; Health Statistics Biostatistics & Epidemiology Group, University of Plymouth, Tamar Science Park, Plymouth, United Kingdomb; and HealthCare Science Limited Hitchin, Hertfordshire, United Kingdom.c Address correspondence to Andrew J. Smith BDS, FDS, RCS, PhD, FRCPath, Infection Research Group, Level 9, Glasgow Dental Hospital and School, Faculty of Medicine, 378 Sauchiehall St, Glasgow G2 3JZ, Scotland. E-mail: [email protected]. Supported by a grant from the Scottish Prison Service. Conflicts of interest: None to report. 0196-6553/$36.00 Copyright ª 2009 by the Association for Professionals in Infection Control and Epidemiology, Inc. doi:10.1016/j.ajic.2009.04.282
The aims of this study were to assess, against current standards, the procedures presently used during the instrument decontamination cycle in centers providing dental care in the Scottish Prisons Service (SPS).
METHODS The study population comprised all prisons that undertake dental treatment of inmates in the SPS (n 5 15). Prior to each visit, a letter was sent to the prison health center manager and prison dental practitioner, outlining the nature of the study and documentation required for inspection on the day of the survey visit. The data collection forms provided questions designed to investigate compliance with extant guidance documents on decontamination.4 Each surgery survey was undertaken by a team of surveyors; a prison had only 1 dental treatment area. This team comprised 1 infection control/decontamination expert and 1 experienced dental practitioner. On the morning or afternoon of the visit, the prison surgery was closed to patients. The survey team interviewed the dental practitioner and surgery nurse and reviewed documentation relevant to the survey and decontamination processes. The survey visits took place in 2005.
RESULTS All sites were visited except 1, which did not participate because of staff changes at this site. The majority of the 14 dental surgeries visited in the SPS had been purpose built (71%, n 5 10). In 64% (n 5 9) of surgeries, the area for decontamination was not physically separated from other work areas, and a wide variety of activities were undertaken in the same area such as radiograph processing, preparation of restorative 689
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materials, air compressor, medical treatment room, food, and as a general work surface. There was a median of 15 attendances for treatment per day in each surgery, with a range of 5 to 28. All the surgeries visited undertook a wide range of critical and semicritical procedures, ranging from routine restorative dentistry, mucosal biopsies, simple and surgical extractions, and routine and surgical periodontal treatment. Sixty-four percent of surgeries (n 5 9) had a documented management policy. An audit of infection control procedures had been undertaken in 29% (n 5 4) of surgeries. Virtually all (93%, n 5 13) of the surgeries used manual washing as either the sole method or as part of the cleaning process. Seventy-one percent (n 5 10) of the surgeries had a designated sink that was used only for instrument cleaning. The manual washing process was generally poorly controlled, with 14% (n 5 2) of surgeries not using any cleaning agent other than water. Only 7% (n 5 1) of surgeries used a detergent formulated for manual washing of surgical instruments, with 43% (n 5 6) using surgical handwash. Ultrasonic baths were present in 79% (n 5 11) of surgeries. The cleaning agent most commonly used was an enzymatic detergent (64%, n 5 9). No surgeries undertook periodic tests of the cleaning efficacy of the ultrasonic bath. The most common type (86%, n 5 12) of sterilizer used was a bowl and instrument sterilizer with the remaining 2 surgeries using vacuum-type bench top sterilizers. In most cases, it was difficult to determine, from the quality of the documentation available, whether appropriate periodic testing was undertaken. Fifty percent (n 5 7) of surgeries did not undertake testing of the sterilizer at the beginning of each day. Neither of the vacuum bench top sterilizers underwent appropriate daily tests to demonstrate efficacy of air removal. Written instructions for operation of the sterilizer were available in 36% (n 5 5) of surgeries. No sterilizer was fitted with a chart recorder or data logger. According to paperwork made available to the survey team members, insurance cover for the pressure vessels was only available in half of the surgeries. None of the surgeries had any form of traceability systems for their reusable devices. There was no documentation of staff training in the use of sterilizers in 79% (n 5 11) of surgeries.
DISCUSSION The methodology of this survey, which employed direct interviews with dental surgeons and dental nurses in the workplace and observed the decontamination processes first hand, has provided high-quality data.3-5 Despite many of the dental surgeries being purpose built, many suffered from inadequate space to function effectively as a dental surgery and instrument
American Journal of Infection Control October 2009
decontamination facility. This potentially complicates the separation of decontamination from clinical areas, a fundamental problem identified in many surgeries visited. Thorough cleaning of reusable medical devices is an essential prerequisite to producing sterilized instruments. Instrument cleaning has emerged from this survey as an area in which significant improvement is required. Manual cleaning, alone or in combination with other cleaning processes, is the most common method and is carried out in the virtual absence of any form of quality control. Of further concern was the inadequate separation of clean and dirty instruments; in some instances, this may lead to the inadvertent reuse of instruments that have not been sterilized. There was little evidence of clear management processes underlying decontamination procedures in most surgeries; audit of instrument decontamination was undertaken in only 29% (n 5 4) of surgeries, and much of the training in procedures such as autoclave use is provided by word of mouth and demonstration within the surgery, with little documentation of training. In conclusion, the decontamination of dental instruments in the SPS has several shortcomings in both the reprocessing of dental instruments and the design and set-up of existing dental surgeries. In light of the relatively low volume of treatment undertaken in the SPS, we suggest that the many of the shortcomings identified in this survey could be overcome, in a costeffective manner, by outsourcing instrument reprocessing to a central sterile service department.6 The authors thank the staff within the Scottish Prison Service for their kind help and support, without which the survey could not have taken place. References 1. Centers for Disease Control and Prevention. Guidelines for infection control in dental health care settings—2003. Morb Mortal Wkly Rep 2003;52(RR-17):1-66. 2. Health Department Letter 2001 66 (8/20/2001): Healthcare associated infection: review of decontamination services and provision across NHS Scotland. The decontaminationof surgical instruments and other medical devices. Report of a Scottish Executive Health Department Working Group. Available from: http://www.show.scot.nhs.uk/sehd/pu blications/sspr/sspr-00.htm. Accessed August 28, 2009. 3. Bagg J, Smith AJ, Hurrell D, McHugh S, Irvine G. Pre-sterilization cleaning of re-usable instruments in general dental practice. Br Dent J 2007;202:E22. Available from: doi: 10.1038/bdj.2007.125. Accessed August 28, 2009. 4. Smith AJ, Hurrell D, Bagg J, McHugh S, Mathewson H, Henry M. A method for surveying instrument decontamination procedures in general dental practice. Br Dent J 2007;202:E20-E23. Available from: doi: 10.1038/bdj.2007.124. Accessed August 28, 2009. 5. Bagg J, Smith AJ, Hurrell D, McHugh S. Sterilization of re-usable instruments in general dental practice. Br Dent J 2007;202:E22. Available from: doi: 10.1038/bdj.2007.124. Accessed August 28, 2009. 6. Wilson APR, Brent D, Beckett G. Benchtop sterilizers and CSSD. J Hosp Infect 1999;43:246-7.
We describe an observational study in which the policies and procedures of dental surgeries in 14 of the 15 Scottish prisons for sterilizing instruments were viewed directly by a trained surveyor. The survey found that several key elements in the decontamination cycle, ranging from procurement of devices, cleaning, sterilizing, testing, maintenance, quality management and training were deficient in a number of aspects. The use of a central sterile supply service may be a more cost effective approach for the provision of compliant instrument reprocessing facilities in the sites surveyed. Key Words: Dental; instrument cleaning; instrument sterilization; infection control; prison service. Copyright ª 2009 by the Association for Professionals in Infection Control and Epidemiology, Inc. (Am J Infect Control 2009;37:689-90.)
We describe an observational study in which the policies and procedures of dental surgeries in 14 of the 15 Scottish prisons for sterilizing instruments were viewed directly by a trained surveyor. The survey found that several key elements in the decontamination cycle including procurement of devices, cleaning, sterilizing, testing, maintenance, quality management, and training were deficient in a number of aspects. The use of a central sterile supply service may be a more cost-effective approach for the provision of compliant instrument reprocessing facilities in the sites surveyed. The effective cleaning and sterilization of dental instruments is a core component of standard infection control precautions, previously referred to as Universal Precautions.1 The cleaning and sterilization of dental instruments comprises a number of interlinked processes with several critical control points.2 The reprocessing of instruments in both acute and primary care facilities has been shown to be suboptimal in many cases.2,3 From the Infection Research Group, University of Glasgow Dental School, Glasgow Dental Hospital and School, Faculty of Medicine, Glasgow, Scotlanda; Health Statistics Biostatistics & Epidemiology Group, University of Plymouth, Tamar Science Park, Plymouth, United Kingdomb; and HealthCare Science Limited Hitchin, Hertfordshire, United Kingdom.c Address correspondence to Andrew J. Smith BDS, FDS, RCS, PhD, FRCPath, Infection Research Group, Level 9, Glasgow Dental Hospital and School, Faculty of Medicine, 378 Sauchiehall St, Glasgow G2 3JZ, Scotland. E-mail: [email protected]. Supported by a grant from the Scottish Prison Service. Conflicts of interest: None to report. 0196-6553/$36.00 Copyright ª 2009 by the Association for Professionals in Infection Control and Epidemiology, Inc. doi:10.1016/j.ajic.2009.04.282
The aims of this study were to assess, against current standards, the procedures presently used during the instrument decontamination cycle in centers providing dental care in the Scottish Prisons Service (SPS).
METHODS The study population comprised all prisons that undertake dental treatment of inmates in the SPS (n 5 15). Prior to each visit, a letter was sent to the prison health center manager and prison dental practitioner, outlining the nature of the study and documentation required for inspection on the day of the survey visit. The data collection forms provided questions designed to investigate compliance with extant guidance documents on decontamination.4 Each surgery survey was undertaken by a team of surveyors; a prison had only 1 dental treatment area. This team comprised 1 infection control/decontamination expert and 1 experienced dental practitioner. On the morning or afternoon of the visit, the prison surgery was closed to patients. The survey team interviewed the dental practitioner and surgery nurse and reviewed documentation relevant to the survey and decontamination processes. The survey visits took place in 2005.
RESULTS All sites were visited except 1, which did not participate because of staff changes at this site. The majority of the 14 dental surgeries visited in the SPS had been purpose built (71%, n 5 10). In 64% (n 5 9) of surgeries, the area for decontamination was not physically separated from other work areas, and a wide variety of activities were undertaken in the same area such as radiograph processing, preparation of restorative 689
690
Smith, Creanor, and Hurrell
materials, air compressor, medical treatment room, food, and as a general work surface. There was a median of 15 attendances for treatment per day in each surgery, with a range of 5 to 28. All the surgeries visited undertook a wide range of critical and semicritical procedures, ranging from routine restorative dentistry, mucosal biopsies, simple and surgical extractions, and routine and surgical periodontal treatment. Sixty-four percent of surgeries (n 5 9) had a documented management policy. An audit of infection control procedures had been undertaken in 29% (n 5 4) of surgeries. Virtually all (93%, n 5 13) of the surgeries used manual washing as either the sole method or as part of the cleaning process. Seventy-one percent (n 5 10) of the surgeries had a designated sink that was used only for instrument cleaning. The manual washing process was generally poorly controlled, with 14% (n 5 2) of surgeries not using any cleaning agent other than water. Only 7% (n 5 1) of surgeries used a detergent formulated for manual washing of surgical instruments, with 43% (n 5 6) using surgical handwash. Ultrasonic baths were present in 79% (n 5 11) of surgeries. The cleaning agent most commonly used was an enzymatic detergent (64%, n 5 9). No surgeries undertook periodic tests of the cleaning efficacy of the ultrasonic bath. The most common type (86%, n 5 12) of sterilizer used was a bowl and instrument sterilizer with the remaining 2 surgeries using vacuum-type bench top sterilizers. In most cases, it was difficult to determine, from the quality of the documentation available, whether appropriate periodic testing was undertaken. Fifty percent (n 5 7) of surgeries did not undertake testing of the sterilizer at the beginning of each day. Neither of the vacuum bench top sterilizers underwent appropriate daily tests to demonstrate efficacy of air removal. Written instructions for operation of the sterilizer were available in 36% (n 5 5) of surgeries. No sterilizer was fitted with a chart recorder or data logger. According to paperwork made available to the survey team members, insurance cover for the pressure vessels was only available in half of the surgeries. None of the surgeries had any form of traceability systems for their reusable devices. There was no documentation of staff training in the use of sterilizers in 79% (n 5 11) of surgeries.
DISCUSSION The methodology of this survey, which employed direct interviews with dental surgeons and dental nurses in the workplace and observed the decontamination processes first hand, has provided high-quality data.3-5 Despite many of the dental surgeries being purpose built, many suffered from inadequate space to function effectively as a dental surgery and instrument
American Journal of Infection Control October 2009
decontamination facility. This potentially complicates the separation of decontamination from clinical areas, a fundamental problem identified in many surgeries visited. Thorough cleaning of reusable medical devices is an essential prerequisite to producing sterilized instruments. Instrument cleaning has emerged from this survey as an area in which significant improvement is required. Manual cleaning, alone or in combination with other cleaning processes, is the most common method and is carried out in the virtual absence of any form of quality control. Of further concern was the inadequate separation of clean and dirty instruments; in some instances, this may lead to the inadvertent reuse of instruments that have not been sterilized. There was little evidence of clear management processes underlying decontamination procedures in most surgeries; audit of instrument decontamination was undertaken in only 29% (n 5 4) of surgeries, and much of the training in procedures such as autoclave use is provided by word of mouth and demonstration within the surgery, with little documentation of training. In conclusion, the decontamination of dental instruments in the SPS has several shortcomings in both the reprocessing of dental instruments and the design and set-up of existing dental surgeries. In light of the relatively low volume of treatment undertaken in the SPS, we suggest that the many of the shortcomings identified in this survey could be overcome, in a costeffective manner, by outsourcing instrument reprocessing to a central sterile service department.6 The authors thank the staff within the Scottish Prison Service for their kind help and support, without which the survey could not have taken place. References 1. Centers for Disease Control and Prevention. Guidelines for infection control in dental health care settings—2003. Morb Mortal Wkly Rep 2003;52(RR-17):1-66. 2. Health Department Letter 2001 66 (8/20/2001): Healthcare associated infection: review of decontamination services and provision across NHS Scotland. The decontaminationof surgical instruments and other medical devices. Report of a Scottish Executive Health Department Working Group. Available from: http://www.show.scot.nhs.uk/sehd/pu blications/sspr/sspr-00.htm. Accessed August 28, 2009. 3. Bagg J, Smith AJ, Hurrell D, McHugh S, Irvine G. Pre-sterilization cleaning of re-usable instruments in general dental practice. Br Dent J 2007;202:E22. Available from: doi: 10.1038/bdj.2007.125. Accessed August 28, 2009. 4. Smith AJ, Hurrell D, Bagg J, McHugh S, Mathewson H, Henry M. A method for surveying instrument decontamination procedures in general dental practice. Br Dent J 2007;202:E20-E23. Available from: doi: 10.1038/bdj.2007.124. Accessed August 28, 2009. 5. Bagg J, Smith AJ, Hurrell D, McHugh S. Sterilization of re-usable instruments in general dental practice. Br Dent J 2007;202:E22. Available from: doi: 10.1038/bdj.2007.124. Accessed August 28, 2009. 6. Wilson APR, Brent D, Beckett G. Benchtop sterilizers and CSSD. J Hosp Infect 1999;43:246-7.