Newsletter: November 2019

The risk to the public that results from a practitioner’s non-compliance with the Infection prevention and control (IPC) practice standard is likely to be viewed by the Council as gross negligence amounting to malpractice, rather than a competence issue, and referred to a professional conduct committee for investigation.

The responsibility for complying with the IPC practice standard rests with the registered oral health practitioner.

Each time you apply for an annual practising certificate, you are asked to declare that you comply with the Council’s ethical principles, professional and practice standards. The questions we ask include:

“Do you understand and comply with the following practice standards as required by Dental Council” and specifically, “Infection Prevention and Control - Yes or No”.

Most practitioners tick the “yes” box indicating they believe they are complying with this standard. However, this is not always accurate.

Case commentary

Despite ticking “yes” to compliance questions in APC application forms, a practitioner has been found to be well-short of compliance.

The practitioner was referred to a professional conduct committee (PCC) for investigation following a significant breach of the IPC practice standard. The practitioner’s autoclave had not been validated for three years and the practitioner had failed to perform any daily testing or logging of cycles, as required by the IPC standard.

Fortunately for the practitioner’s numerous patients, the autoclave subsequently passed all testing and was validated, but this could easily have not been the case. This was a significant ‘near-miss’ situation – placing the health of numerous patients at risk.

The PCC view was that the practitioner appeared to be unaware of their obligations regarding infection control, rather than being knowingly non-compliant. The practitioner’s response was immediate and appropriate once they became aware of the IPC requirements.

The PCC expressed a view that the lack of frequent formal or informal peer contact were likely to have been a factor in the practitioner’s not knowing about the standards. Nevertheless, this was a serious matter and a significant professional failing by the practitioner concerned.

Practitioners are individually responsible to know and comply with their professional obligations.

What the studies show

Earlier this year, the New Zealand Dental Journal (March 2019, Vol. 115) published a study on New Zealand oral health practitioners’ cross infection control practices. The purpose of the study was to update information on New Zealand dentists’ and allied dental practitioners’ adherence to protocols current at the time of the study (data were collected between March and July 2016).

The key points to note from the findings are:

• 889 oral health practitioners were randomly selected for the national study, and the response rate was 39.7%
• fewer than half of the practitioners (45.2%) had read the Dental Council’s cross infection control-related documents current at the time of the study
• the study concluded that most New Zealand practitioners are following cross infection control protocols, but a number are still not doing so, putting patients and the dental team at risk.

A recent desktop audit of some Combined Dental Agreement holders indicated that only 33% of those surveyed had correct validation records of reprocessing equipment.

Council’s concerns

The Council is concerned about compliance with the IPC practice standard and the public risk if infection control measures are not adequate.

This concern is based on the practitioner cases considered by the Council and its review of Council practice audit results – these show practitioners are consistently falling short of our compliance requirements in some areas including:

• the current requirements and guidelines for hand hygiene are not always well understood
• the classification of instruments as semi-critical or critical could be based on the use of the instrument rather than the instrument itself
• the prevention of airborne infections and managing aerosols requires materials and instruments within the primary clinical area to be protected from contamination – including cotton rolls and pellets, bur stands and orthodontic pliers
• personal protective equipment during reprocessing instruments is necessary – some audits have revealed that even though the equipment is available on site, it is not always used by busy staff in the sterilising room
• when asked, some practitioners find it difficult to confirm the safety of the water supply to equipment
• most practitioners indicate that they comply with the documentation requirements of the infection prevention and control practice standard, but when asked, are uncertain about the exact documents referred to.

The documentation required to comply with the IPC practice standard include (see page 46 of the standard):

• infection prevention and control practice manual – this must be available and reviewed every two years
• infection prevention and control records – the following records must be kept for a minimum of 10 years:
• monitoring records for sterilisation cycles, instrument washers, ultrasonic cleaners, instrument washers
• maintenance records – from a qualified contractor
• validation records at IQ, OQ, PQ and annual re-qualification (undertaking regular servicing of autoclaves, and conducting and appropriately recording the required daily tests is essential)
• education and training – staff at orientation, and refresher staff training
• incident records
• critical item tracking – the cycle number needs to be transferred to the patient records for critical items.

Back to some basics

Gloves are now worn universally in dental practice but there is some confusion over the appropriate type. For general dental procedures, non-sterile examination gloves that comply with AS/NZS 4011 are adequate. When sterile field is required – for example, oral surgery, surgical extractions, periodontal surgery, implant treatment – it is essential that instruments are laid out on a sterile surface and sterile gloves that comply with AS/NZS 4179 are used.

At present, there are concerns about measles in the community. Oral health practitioners must ensure they have the basic transmission-based precautions in place at all times to supplement the standard precautions, such as providing alcohol-based hand rub, tissues and face masks in reception areas, and ensuring surfaces touched by patients are cleaned appropriately.

Practitioners must ensure that not only their own clinical practise meets the IPC practice standard but that these standards are fully met in the practice in which they work. The “practice” is defined as all settings where a registered oral health practitioner performs activities associated with their scope of practice, so vigilance is required when practitioners work in more than one practice setting, such as rest homes or care facilities.

Another serious breach of Council’s IPC practice standard

Another case recently referred to the Council involved a group practice with multiple clinicians.

At the end of a morning session a dental assistant (DA) prepared the tray of instruments, bagged them, and placed them in the autoclave expecting that another DA would be soon finished and would need to reprocess their instruments too.

After lunch, another DA thought the autoclave had completed its cycle. They picked up the unsterilised instruments, took them to another surgery and used them on the first patient of the afternoon.

Although inadvertent, this was a serious breach of protocols and could pose a significant risk of harm to patients. It may be possible for a colour change to occur when pouches are placed in an autoclave chamber that has not completely cooled. The appearance of pouches changes after a cycle but a label on the autoclave indicating status (dirty or clean) would reduce the risk of such a breach of protocol.

Checklists and systems are important in practices to avoid this sort of breach, especially when there is no dedicated staff member responsible for reprocessing.

You can self-audit your compliance at any time

Practice standards compliance self-audit questionnaires are available on the Council’s website. You can download the questionnaire for your profession at any time and check your compliance.

At the time you apply for your APC, as well as regularly during the year, the self-audit questionnaire is a useful tool to reflect on your compliance. It works best when the standards are read carefully, and the questions answered with specific reference to those standards.

It is also worthwhile using the audit as an opportunity to include all staff in the practice with a view to identifying any changes that may improve performance and patient safety. To undertake the process with a colleague from another practice has some merit too, as it is an opportunity to see things through a fresh set of eyes.

Practitioner’s responsibility

The Council reminds all practitioners they must be knowledgeable on infection prevention and control measures set out in the IPC practice standard. You should refresh your knowledge at least annually.

Remember, the responsibility for infection prevention and control and complying with each requirement of the IPC practice standard rests with the registered oral health practitioner.