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NHSScotland: Sterile Services Provision Review Group: Survey of Decontamination in General Dental Practice
SECTION 4: DISCUSSION
4.1 Methodology
This is the largest study ever completed which has surveyed, by direct observation, decontamination procedures in general dental practices. 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. The robustness and accuracy is significantly greater than that gathered through postal questionnaires, which to date have been the main source of such information
16.
Anecdotally, all the survey teams reported the enthusiasm and willingness of the staff in the participating practices to co-operate fully during each visit and their requests for guidance on appropriate decontamination protocols.
4.2 Results
We would like to draw attention to the deficiencies in centrally held databases of activity in general dental practice. Incomplete and inaccurate data have seriously hindered recruitment of dentists into the survey and have implications for other studies into delivery of dental care to the Scottish population.
The overall findings of this survey bear striking similarities to those from the central sterile departments and acute sectors
5,17. Central to these has been the observation of highly motivated staff attempting to comply with infection control guidelines available to them and according to their own interpretation. However, the need for more detailed practical guidance to dental personnel on implementation of the technical requirements implicit in high quality decontamination cannot be over-stressed.
The results reported here support the earlier findings from a smaller number of practices surveyed in Scotland
5, England and Wales
17. Therefore the recommendations of this study are relevant to the whole of the UK.
Re-use of single use devices
This topic highlights key issues over labelling of devices, manufacturers' instructions and users' knowledge. Some devices, such as impression trays, are clearly labelled as single use. Other devices, such as endodontic files, are labelled as single use by some manufacturers whilst other manufacturers supply decontamination instructions that are incompatible with common practices in the UK. In addition there is evidence that some devices, such as Siqveland matrix bands, can be especially problematic
18,19. Although guidance has been issued
20 recommending that the matrix bands must not be re-used there are a number of practitioners who continue to decontaminate and re-use assembled bands for treatment of multiple patients.
Premises
During the course of the survey, many types of premises were visited, but only a very small proportion were purpose-built as dental surgeries and the majority were remote from other healthcare providers. This potentially complicates the separation of decontamination from clinical areas, a fundamental problem identified in many practices visited and one which must be overcome if dental surgeries are to continue acting as local decontamination units (LDUs).
Management and quality assurance
There was little evidence of clear management processes underlying decontamination procedures in most practices and audit of instrument decontamination was virtually non-existent. Whilst cumbersome management procedures are clearly inappropriate for busy dental practices, guidance for dental staff on the various elements of process control is essential and required urgently, since ensuring and recording the quality of the process of decontamination is the only safeguard for the supply of adequately sterilized dental instruments.
Instrument procurement
The concept of instrument procurement as an element of the decontamination cycle must be stressed to dental staff. Currently most instrumentation is ordered by phone from a dental supplier, with little consideration for the compatibility of
decontamination instructions as supplied by the manufacturer, in relation to the practice's current procedures. This process could be improved dramatically if
dentists were provided with recommended specifications for particular items, which they could then use as a guide during purchasing.
Equipment manufacturers and suppliers
The safe and efficient decontamination of dental instruments by dental practitioners is seriously hindered by the lack of clear information from the majority of manufacturers / suppliers. Appropriate instructions for reprocessing many dental devices are either absent or incompatible with common processes in use in the UK, for example, "operate at a sterilizing temperature and pressure of 134° C for 12 minutes, followed by a 20-30 minute drying time." Another example recommends sterilizing with an autoclave at 134° C "during 5 min at 3 bars." This in turn raises questions over the effectiveness of the appropriate regulatory bodies in the UK.
Equipment installation, testing and maintenance
The majority of items of dental equipment essential to the decontamination process, such as ultrasonic baths and benchtop steam sterilizers, are not commissioned on installation or tested at appropriate intervals as recommended in a number of technical publications. The nature of the sterilization process requires validation of equipment, confirmed at regular intervals by appropriate testing. Many practices subscribing to third party testing and maintenance schedules had insufficient paper work to support the efficacy of these visits. Guidance is required to provide appropriate value for money and assurance for dental practitioners that relevant testing and maintenance is undertaken by appropriately trained engineers.
Instrument cleaning
Previous risk assessments of the potential transmission of vCJD via surgical instruments
3,6 have stressed the importance of cleaning of instruments prior to the sterilization phase. Instrument cleaning has emerged from this survey as an area where significant improvement is required urgently. 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. Many practices use only tap water, in the total absence of a cleaning agent, and those who use a
cleaning agent often choose one that is entirely inappropriate, for example surgical hand wash. Rinsing is typically with tap water in the same sink as the manual cleaning and most practices do not dry instruments after cleaning. Most practices used ultrasonic cleaners in addition to, or instead of, manual cleaning. The frequency with which the ultrasonic bath liquid was cleaned was variable and virtually no practices undertook any testing of the efficacy of the ultrasonic cleaner.
Instrument sterilization
In relation to instrument sterilization, most practices used bowl and instrument sterilizers. Although most practices had a maintenance contract, the majority of practices were unaware of the existence of SHTM 2010 and it was difficult on most visits to ascertain from the paperwork made available whether regular testing of the autoclaves was undertaken in accordance with that document. Many autoclaves had not been tested or commissioned on installation. Some practices had failed to obtain pressure vessel insurance which is in breach of Health and Safety Laws. The quality of water used in the autoclave reservoirs ranged from tap water to sterile water and the frequency of draining the reservoir was also variable, though some were following the recommendation of daily drainage and replacement. Some practices were still packaging instruments before loading them into a bowl and instrument sterilizer, though significantly more were packaging after sterilization.
Staff training
An urgent requirement for staff training has emerged from this survey. At present, much of the training in procedures such as autoclave use is provided by word of mouth and demonstration within the practice and there is only scanty documentation of training. It was the view of many of the surveyors who took part in this study that the dental staff were very keen to be given practical, pragmatic guidance on the procedures necessary to improve the standards of instrument decontamination being practised.
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