Making the working environment safe
The aim of this chapter is to familiarise the dental team with an outline of the measures to make the working environment safe. This includes general issues, personal protection and instrument safety.
The chapter should lead to an understanding of the importance of a safe working environment and how it may be best achieved, including methods to protect the members of the dental team and methods to ensure that instruments are clean and sterile.
There are many aspects to safety in the working environment. These include processes and requirements common to any working environment, such as fire precautions, electrical safety and the safe use of equipment, together with many other measures devised to protect both those who work in the environment and others who visit the workplace for whatever purpose. There are, in addition, processes and requirements for specific types of workplace, with clinical workplace environments being no exception. In the clinical workplace, and in particular environments for the provision of oral healthcare, there are many varied processes and requirements, which vary in their nature and extent according to the type of patient being treated and the treatment provided. These processes and requirements may vary nationally and internationally, but they are increasingly the subject of international guidance and common expectations of good practice.
In this chapter, special attention is paid to two areas, personal protection and the decontamination of instruments in the dental clinical environment, with an emphasis on the dental practice rather than the hospital or other community-based clinical environment. This emphasis is not intended to belittle or otherwise down-play the critical importance of other aspects of safety in the dental workplace environment. The other aspects of safety in the dental workplace include safety in respect of the use of ionising radiation and pressure vessels; the storage and dispensing of drugs; the dispatch and receipt of clinical materials, including work to be sent and received from the dental laboratory; the storage, use and disposal of hazardous substances; and special safety precautions for patients with special needs. The reader is referred to relevant legislation, national and international guidance and other literature that deal with such matters in detail. Keeping abreast of all relevant developments in respect of safety is challenging.
As a guiding principle, the working environment should pose no threat to anyone who works in it or has occasion to visit it. Workers and visitors should feel safe and secure in the workplace environment, free of any feelings of unrecognised, uncontrolled dangers and hazards. Safety in the workplace should be the subject of regular audit and risk assessment, possibly involving external assessments and other form of inspection. Safety is difficult to ensure in a clinical environment that is outdated or poorly maintained. Modern design and facilities greatly assist the management of safety issues.
Irrespective of care and attention paid to safety, there is always some risk of untoward events. To be prepared to deal with such events, there should be provisions and training in the workplace for matters ranging from first aid, including basic life support, to procedures to be followed in the event of a major incident such as a fire.
Safety in the workplace is an individual and collective responsibility. All relevant safety procedures and arrangements should be second nature to the dental team. To achieve this, the dental team should develop detailed written protocols that are both kept up to date and rehearsed from time to time, ideally on a regular basis.
Safety is not an option, it is fundamental to modern clinical practice and to fulfilling one of the dental team’s principal professional responsibilities: protection of the patient.
Safety in the workplace should be the subject of regular audit and risk assessment.
Safety in the workplace is an individual and collective responsibility.
Safety is not an option, it is fundamental to modern clinical practice.
With the emergence of new infectious diseases and increasing prevalence of blood-borne viral diseases, including HIV and hepatitis B and C, the importance of personal protection in the dental clinical environment has grown dramatically. Depending on local and national requirements, all clinical members of the dental team may need to be successfully immunised against diphtheria, hepatitis B, pertussis, poliomyelitis, rubella, tetanus and tuberculosis.
‘Super bugs’, microorganisms resistant to many of the usual antimicrobial agents, and their impact on healthcare continue to have a high media profile. As a result, patients are increasing aware of infection risks in clinical environments and the requirements of health professionals to observe infection control procedures. This increased awareness leaves patients expecting to observe such activities when visiting healthcare environments; dental surgeries are no exception.
A key element of infection control recommended by authorities worldwide is the concept of standard precautions as a means to reduce disease transmission. The primary concept is that all patients are potentially infectious, as most carriers of infection are unaware of their condition.
This necessitates the implementation of a comprehensive infection control procedure. The World Dental Federation recommends that all oral health professionals adhere to standard precautions as set by the local or regional authorities, as appropriate.
Every dental practice, hospital and laboratory will have a written infection control policy tailored to their individual routines.
Employers have a duty to ensure that all members of staff are satisfactorily trained. This training should include:
how infections are transmitted
preparing a practice policy on decontamination and infection control
what personal protection is required and when to use it
what to do in the event of accidents or personal injury.
The entire dental team is responsible for implementing, complying and keeping up to date in respect of infection control procedures.
The information relating to infection control procedures is wide ranging. This section provides an introduction to policies that may impact on the personnel of the dental team. This information is, however, by no means exhaustive and further reading is recommended.
Dental professionals have an ethical obligation to provide treatment for all patients. As a consequence, infection control policies must be universally applied; this is of particular importance given that most carriers of latent disease are unaware of their condition and some patients may not wish to disclose information at all. Patient information and the medical history help in assessing any risks of potential infection to the dental team and other patients.
From this information, procedures in line with standard precautions can be implemented to protect practice staff, patients and laboratory personnel. Any disclosures by the patients must be treated confidentially and should not be passed to any other party without the prior consent of the patient. The matter of disclosure and confidentiality is further expanded in Chapter 3.
A medical history must always be taken at the first visit to the practice and should be updated on a regular basis. All relevant information must be carefully recorded as part of the patient’s clinical record and updated as appropriate.
All members of the dental team need to understand the principles of personal protection and comply with relevant policies, including those pertaining to immunisation. Personal protection involves a range of measures.
Protective clothing includes uniforms, which will have certain material requirements for safety, and various items for specific purposes. At times, protective clothing is a personal choice; however, the following points should be considered.
The material forming the protective clothing should be capable of withstanding temperatures of 65°C to allow for effective washing to eliminate any potential microbial contamination. The style of the protective clothing may vary according to the procedures being undertaken and the potential for contamination. Increasingly, chairside personnel are adopting short-sleeved tunics or tops, leaving the forearms bare. This facilitates washing of the hands, including the wrists and forearms, and is most acceptable to patients. When undertaking procedures that involve the production of large amounts of splatter or aerosol contaminated with saliva or blood, the protective clothing may be protected by a disposable, single-use plastic apron, which covers the thighs in the sitting position. Given such measures, a protective tunic or top may itself be worn for a whole clinical session, possibly even a day, unless it becomes frankly contaminated or otherwise soiled.
Protective clothing should not be worn outside the practice or hospital environment. Long-sleeved gowns, increasingly of a disposable, single-use type, continue to be used for surgical procedures. Such gowns are donned after scrubbing-up and prior to putting on single-use, disposable, sterile surgical gloves.
Other protective clothing should include footwear that will protects the feet from falling instruments and made of a material that is non-absorbent, ideally with a smooth, shiny, impervious surface. It is good practice to change out of outdoor footwear into clinical footwear prior to a clinical session.
Safety glasses should be worn by all members of the dental team and patients (Fig 5-1). Safety glasses help to protect eyes against trauma and contamination from foreign bodies, splatter and droplets in aerosols. Prescription glasses, if worn by the patient, should be removed and replaced by protective glasses. If the chairside members of the dental team wear prescription glasses, the options are the use of a facial shield (visor), which many clinicians prefer to the use of protective glasses, the use of protective glasses that cover the prescription glasses, or the use of protective glasses including prescription lenses. Whatever form of eye or facial protection is used, it is important to have side protection, provided by side wings to the protective glasses or a facial shield curving round the side of the face. If the operator wishes to use loupes, these should be fixed to the protective eyewear. Facial shields should be changed between patients. The surfaces of protective glasses need to be thoroughly cleaned with a surface disinfectant between patients, care being taken to avoid residual disinfectant on the glasses, which could irritate the eye. Protective eyewear should be worn as a matter or routine while undertaking laboratory work
A close-fitting face mask that covers the nose and mouth should be worn by all chairside members of the dental team when undertaking all forms of treatment. Face masks must be changed between patients and as and when they become moist during a prolonged procedure. Members of the dental team working in the dental laboratory should wear a face mask whenever generating dust and aerosols.
Good hand hygiene is the single most important infection control measure. Chairside members of the dental team should wash their hands with a detergent or liquid soap intended for clinical use:
whenever the hands become soiled, dirty or contaminated
before and after eating and drinking
before and after going to the toilet
after coughing, sneezing or nose blowing
after touching, rubbing or scratching skin or hair
when starting or completing clinical sessions.
The technique for routine hand washing is illustrated in Fig 5-2. It is important to remove all jewellery, wrist watches and other items prior to all clinical sessions, the only possible exception being a simple, s/>