Dental Department JCI Accreditation

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Introduction

This project involved preparing the dental department to obtain the Joint Commission International (JCI) accreditation. On this note, it will cover at least 12 various areas to ensure optimal dental care, including infection control program, dental personal health programme, preventing transmission of blood borne pathogens, hand hygiene and personal protective equipment among others.

For dental departments, accreditation from the JCI is regarded as the global standard through which any healthcare department is demonstrated to provide high quality and healthcare services that meet the minimum required standards and guidelines as provided by different local, regional and global quality assurance bodies. For instance, the public want and deserve quality healthcare and improved outcomes whether it is for dental, surgical procedures or any other clinical interventions. In addition, patients should know the qualifications of their dentists, observe cleanliness at the facility and they be assured that all treatment procedures follow the recommended standards to reduce cases of medical errors, negligence and infection.

It is noteworthy that healthcare facilities in the US are usually accredited based on agreed upon best standards of practices. The same, however, cannot be said of other many international healthcare facilities. The concept of healthcare tourism has gained recognition in the recent past. On this note, many healthcare facilities strive to get accreditation from various international bodies to ensure that they can offer the best procedures in dental care, fertility management, surgeries or even cosmetic care among others.

The need for accreditation implies that healthcare facilities continue to focus on quality improvements. At the same time, patients also continue to seek for reliable healthcare facilities and dentists with the right expertise in dental care. Once a dental department obtains an accreditation status, it will have the required foundation to become dental care leader in the modern dentistry practice while dentists will apply modern best, evidence-based practices when delivering care to patients.

The dental department will also comply with various laws and regulations of federal, state and local authorities (Thomas, Jarboe, & Frazer, 2008).

Infection Control Programme

In 2003, the CDC provided critical areas that dental departments must observe to ensure effective infection control programme. It included the following provisions for a dental care unit (Centers for Disease Control and Prevention, 2003):

Education and protecting dental health-care professionals (DHCP)
Stopping transfer of bloodborne microorganisms
Hand hygiene
Wearing personal protective equipment
Contact dermatitis and latex hypersensitivity
Sterilization and disinfection of patient-care items
Environmental infection control
Dental unit waterlines, biofilm, and water quality
Special considerations for dental hand pieces and other devices, radiology, injected medications, oral surgical procedures, and dental laboratories

Various stakeholders such as academia, dentists, and public agencies among others developed these elements of infection control programme after careful consultation and collaborations.

In addition, the dental department will have to account for the new recommendations. First, the department will adopt standard precautions instead of relying on the universal ones. Second, it would ensure work restrictions for all DHCPs infected with or those exposed to infectious diseases because of their works. Third, it shall focus on prevention of occupational exposures to bloodborne microorganisms such as “postexposure prophylaxis (PEP) for work exposures to hepatitis B virus (HBV), hepatitis C virus (HCV); and human immunodeficiency virus (HIV)” (Centers for Disease Control and Prevention, 2003). Finally, the dental department will select and use devices that are designed to reduce cases of sharps injuries.

Hand Hygiene

Studies have noted that hand washing is a critical routine procedure in health care settings to prevent the spread of hospital-associated infections caused by MRSA, VRE and other pathogens (Samuel, Almedom, Hagos, Albin, & Mutungi, 2005). It is noted that the current rate of compliance with hand hygiene among general practice dentists (GPDs) is extremely poor (Myers et al., 2008).

For JCI accreditation, the dental department must adhere to hand hygiene procedures as provided by the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) (Canham, 2013). The underlying concept is a practical implication for dentists to conduct regular hand hygiene as required under the guidelines. The major areas of interaction involve patients, dentists and treatment (Centers for Disease Control and Prevention, 2003). Infections may spread at any of these points. Although some dentists may only apply hand hygiene procedures before and after dental care, it is also recommended that they practice these procedures before touching patients and performing aseptic procedures. In addition, they should also observe hand hygiene after body fluid exposure situation, touching patients and/or touching any parts of patients’ environments.

Promoting these areas of hand hygiene can help the dental department to overcome hand hygiene issues and obtain JCI accreditation. For instance, this five-point concept strives to ensure that dentists observe hand hygiene where dental procedures are conducted. Therefore, all hand hygiene materials should be as close as possible to dental care unit and therefore be easily accessed.

The dental department may also enhance hand hygiene procedures by using hand sanitizers. Although hand sanitizers are effective in killing microorganisms, they cannot penetrate debris in hands. In such cases, the CDC recommends thorough washing of hands with an antimicrobial soap and water.

The department will ensure education and feedback on hand hygiene to promote compliance with the main goal of eliminating dirt, germs, reducing the presence of microorganisms on the skin and preventing transmissions of pathogens. Hence, poor hand hygiene will not be a major challenge in the provision of quality health care and improved dental care for patients.

Further, the dental department must enhance the CDC and the WHO hand hygiene knowledge and ensure efficacy of practice and procedures (Centers for Disease Control and Prevention, 2003).

Environmental Infection Control

It has been observed that specific surfaces particularly ones touched more often can act as reservoirs for microorganism and spread infection in dental care units. These places, however, have not been directly linked to transmission of infection to dental health-care professionals (DHCP), patients or support staff (Pine, n.d). Common places may include knobs, switches and light handles among others. It is necessary to clean and disinfect environmental surfaces in a dental facility to protect patients and dentists.

Transfer of microorganisms from contaminated environmental surfaces to patients generally takes place through dentist hand contact (Centers for Disease Control and Prevention, 2003). When these professionals touch such surfaces, they can transfer microorganisms to dental instruments. These microorganisms may be transferred to “patients through their eyes, nose, or mouth” (Centers for Disease Control and Prevention, 2003). Hence, cleaning environmental surfaces is also necessary to guard against healthcare-related infections. There are various environmental surfaces in dental departments, namely contact surfaces and housekeeping surfaces (Pine, n.d). Housekeeping surfaces may include walls, sinks and walls, but they pose limited risks in transferring microorganisms (Pine, n.d).

The dental department will have to develop a specific action plan for cleaning and disinfecting environmental surfaces in care areas. According to the CDC, written standards for operating procedures should include “the potential for direct patient contact; the degree and frequency of hand contact; and potential contamination of the surface with body substances or environmental sources of microorganisms” (Centers for Disease Control and Prevention, 2003).

Cleaning of decontaminated environmental surfaces is required as the initial step for any type of disinfection protocol. The surface would become safe once all reservoirs for microorganisms have been removed.

The dental department must ensure that cleaning is done first to avoid compromising of cleaning procedures. Barriers, which protect environmental surfaces and instruments, are recommended when environmental surfaces may not be effectively cleaned.

Cleaning must also focus on rib holders because they are extremely contaminated with various pathogens, including “E. coli, dead skin cells, strep and staph” (Pine, n.d). The department will use “EPA-registered hospital disinfectant with an HIV, HBV and a tuberculocidal claim for low-level disinfectant and intermediate-level disinfectant” (Centers for Disease Control and Prevention, 2003). There are specific disinfectants for different cleaning purposes such as instruments, rib holders, masks, and hands among others.

It is also recommended that the dental department should adopt technologies to control infections. For instance, Cleankeys keyboard will save time, prevent spilled liquids and food particles from logging between keys. Hand-free tools such as Dental R.A.T reduce frequencies of contacts and aid in probing dental problems.

Preventing Transmission of Bloodborne Pathogens

Cases of bloodborne pathogens such as HBV, HCV, and HIV in dental departments are rare. Nevertheless, they take place. Such risks are generally noted through cases of “patient populations, the nature and frequencies of contacts with blood and body fluids through percutaneous or permucosal routes of exposure” (Centers for Disease Control and Prevention, 2003). Factors such as the “size of inoculums, the path of exposure and the vulnerability of the exposed healthcare professional determine the risk of infection” (Centers for Disease Control and Prevention, 2003).

The dental department must observe that various bloodborne pathogens pose different risks of infection.

The most effective prevention strategy is to avoid exposure and contact with blood. Exposures are common through injuries, infectious blood tissues or through body fluids.

Most these exposures are avoidable. Therefore, the department must observe standard precautions, use suitable devices to reduce risks of injuries and change work practices geared towards safety. A critical focus should be on needlesticks and other potentially infectious materials (OPIM) because they are the most common in dental offices.

For the standard precautions, the dental department would ensure that all healthcare professionals use “personal protective equipment (PPE) such as gloves, masks, gowns and eyewear among others to protect the skin and membrane contacts” (Centers for Disease Control and Prevention, 2003). It also recommended that dentists should wear finger guards during dental procedures.

Using devices designed to reduce risks or engineering controls are fundamental strategies to limit exposures to blood that result from injuries occasioned by sharp objects. The dental department will choose safely designed instruments and use technology-based devices to lessen chances of percutaneous injuries.

Work modification may also help against bloodborne pathogens. Hence, the dental department will introduce the best practices to protect DHCPs who handle, use, assemble or process sharply designed devices.

Work-practice controls establish practices to protect DHCP. These practices will include careful handling of burs prior to dismantling different parts of the unit, controlling the use of fingers in removal of tissues when performing suturing and administering anaesthesia. In addition, the dental department should minimise the use and movement of certain equipment such as laboratory knives.

In case of exposure, the dental department will actively engage in postexposure management to minimise cases of infection for DHCPs (Centers for Disease Control and Prevention, 2003).

Personal Protective Equipment

The equipment is designed to guard against “blood exposures and OPIM that may occur on the mucous membranes of the eye, mouth and nose” (Centers for Disease Control and Prevention, 2003).

The dental department shall ensure that all DHCP have masks, protective eyewear and face shields. It will insist that all DHCPs must wear protective equipment during “operations and other ongoing patient care procedures that are most likely to produce splash or spray other body fluids” (Centers for Disease Control and Prevention, 2003). Protective eyewear with lids is recommended to protect DHCPs against debris and spatter from procedures while surgical masks will protect against microorganisms, large droplets potentially with pathogens or any other infectious pathogens.

The dental department must note that outer surfaces of masks may become “contaminated with infectious body fluid droplets or contact with contaminated fingers” (Centers for Disease Control and Prevention, 2003). Further, exhaled moist air causes the mask to “resist airflow and therefore more air will pass through edges” (Centers for Disease Control and Prevention, 2003). It is therefore recommended that DHCPs should change their masks regularly between or during patient care.

Gloves are necessary to protect DHCPs against contamination of hands when they are exposed to mucous membranes, blood, any body fluids or OPIM. They are also necessary to limit the spread of microorganisms found on hands of DHCPs, which are most likely to be transmitted to patients during care procedures.

Approved medical gloves are recommended for the dental department. DHCPs will ensure that they only use each glove once on a single patient and then discard them. Any torn or punctured gloves must be replaced immediately.

The dental department shall provide protective clothing and equipment such as gowns, gloves and eyewear to all DHCPs. These are necessary to prevent “exposure and contamination of regular cloths and skin from body fluids” (Centers for Disease Control and Prevention, 2003). All protective materials must be OSHA recommended based on the bloodborne pathogens standard needed. For instance, body fluids may spatter or spray to other body parts such as forearms. Dentists will have to change their protective clothing once they notice any signs of body fluid penetration. In addition, they shall leave protective clothing at the right places before leaving work.

Sharp Safety in Dental Clinic

According to Shimoji et al. (2010), dental healthcare workers come in close contact with patients and use a wide range of sharp and high-speed rotating devices relative to other healthcare workers.

The dental department will therefore identify and comprehend different occupational accidents that may take place at the department (Boyce & Mull, 2008).

The CDC provides an effective sharps injury prevention programme for dental departments. The programme includes many aspects that work as unit to eliminate cases of healthcare workers experiencing needlesticks and other sharps-related injuries (Centers for Disease Control and Prevention, 2008). It would enhance performance, control infection and improve safety programmes. The dental department would ensure continuous quality improvement to promote sustainable strategies for sharps injury prevention.

It must focus on two major aspects of the programme. First, the dental department will develop and implement steps for sharps injury prevention programme. Under this programme, the department would focus on a series of administrative and organisational processes. The initial step starts with the creation of a multidisciplinary team to coordinate safety issues. These procedures tend to be consistent with initiatives that strive to improve quality. The plan must be reviewed to ascertain its effectiveness. Second, the programme requires effective operational processes. These are the most critical initiatives in sharps injury prevention programmes. The department, for instance, will encourage DHCPs to create a culture of safety, report sharp injuries, analyse collected data and ensure effective selection and assessment of devices.

On this note, the dental department shall evaluate its sharps injury prevention programmes; document all processes involved in the development and execution of planning and prevention activities; and conduct regular evaluations of programmes’ outcomes.

Effective dental practices shall reduce exposures to sharps injuries. It would ensure that all proper procedures are implemented, particularly sharp devices management and processing procedures. DHCPs will have adequate time to perform their duties. No DHCPs will be allowed to carry sharps and other loose devices on trays across the department to avoid bumping into others and risk causing injuries. The dental department will ensure that DHCPs use only heavy duty, utility gloves to handle sharp instruments instead of patient examination gloves. DHCPs will adhere to all procedures for retrieving instruments.

Dental Personnel Health Programme

The dental department will observe five basic elements for all DHCPs under the programme. These shall include education and training; immunisation schemes; medical conditions, work-related illnesses and work restrictions; exposure prevention and postexposure management; and records maintenance, data management, and confidentiality.

Education and training for DHCPs will be vital for the infection control programme. They will share information and promote learning as their personal responsibilities.

The healthcare facility will inform all DHCPs about possible occupational health risks and identify cases that can be controlled through immunisation. Vaccination against hepatitis B, tetanus and influenza will be highly recommended for all employees.

The dental department exposes DHCPs to several occupational risks. Exposures may take place irrespective of stringent preventive efforts. In this case, the dental department shall develop a thorough postexposure protocol, including medical follow-up after initial interventions. A tuberculosis test, for instance, would be recommended for DHCPs exposed to patients with the condition.

Dental care workers may also develop complications after exposures and outside their duties. Hence, they are most likely to transmit infection to patients. It is therefore recommended that they restrict their works to specific ones as identified by the developed guidelines from the CDC (Centers for Disease Control and Prevention, 2003). A qualified healthcare professional should assist during diagnosis, result interpretation and case management. A written policy should support disclosure and ensure that patients are protected.

The dental department shall keep all medical records of DHCPs, including immunisation histories, various medical conditions and other conditions related to exposures for effective management of potential infections. These records, however, will remain confidential.

Cleaning, Decontamination, Disinfection and Sterilisation

Cleaning procedures will involve the removal of foreign particles and must precede “decontamination, disinfection and sterilisation processes while sterilisation procedures will ensure that the dental department destroy all types of microorganisms” (East Carolina University, 2004). In addition, the dental department will use EPA approved chemicals for disinfection procedures. These agents will inactivate various types of microorganisms (East Carolina University, 2004).

During these procedures, the CSSD unit will classify devices to enhance effective cleaning. Classification is mandatory because the rational for cleaning, decontamination, disinfection and sterilisation is based on the extent of risks posed by different devices.

The dental department will only use EPA registered cleaning and disinfecting agents and they must be carefully assessed before use. Currently, new products are developed to combat resistance from microorganisms and therefore other agents may be replaced.

For optimal safety, the department will consider personnel safety. Only qualified persons shall operate steam sterilisation processing, and they are expected to show high-levels of competence in operating and maintaining autoclave sterilisation systems based on the recommendations from manufacturers. Therefore, better knowledge will help the department to prevent the spread microorganisms (Onana & Ngongang, 2002).

DHCPs must also document their procedures to monitor if all recommended processes have successfully been met. The dental department will promote accountability and reporting of any cases of oversight.

Monitoring records will be evaluated to improve procedures and practices.

Waste Management in Dental Clinic

Several hazardous wastes are found in the dental department and they require proper disposal (Agarwal, Singh, Bhansali, & Agarwal, 2012). They are potentially dangerous to human and the environment.

The dental department will identify and group all mercury-containing wastes as dental amalgam particles or scrap amalgam waste materials. The dental department will ensure that no mercury-containing waste materials escape into the environment or cause harm to DHCPs and patients.

Silver-containing waste materials will not be simply rinsed in the sink. Instead, certain silver-containing waste materials will be effectively diluted with water and then disposed. Under developed X-ray films will be classified as highly toxic and therefore will be sent to recycling company. Further, digital X-ray will be used more often to reduce X-ray waste materials.

All lead-containing waste materials will be handled with great care. No such materials will be sent to landfills for disposal. Instead, they will be taken to a certified biomedical waste carrier (CWC) for recycling or disposal (Agarwal et al., 2012).

The dental department will also generate blood-soaked or dripping gauze, which are extremely hazardous. The department will collect these waste materials using biomedical waste bags and then cover them with double bags labelled with a biohazard symbol and refrigerated for later collection by CWCs.

Sharp devices cause injuries that expose DHCPs to occupational risks. The dental department will ensure that these waste materials are collected in strong, puncture resistant containers and then sealed. Once collected, all labelling should be clear for subsequent collection by CWCs for disposal.

Chemicals, disinfectants and sterilising agents also constitute significant components of waste materials in the dental department. Dry heat or steam will be applied to “sterilise already cleaned, disinfected devices” (Agarwal et al., 2012). No hazardous materials will be disposed down the drain.

Finally, nonhazardous waste materials are also found in the dental department. The department however will minimise their usages, avoid unnecessary usages and support recycling efforts.

Dental Unit Waterline, Biofilm and Water Quality

Past studies have shown that dental unit waterlines consisting of narrow-bore plastic tubing, high-speed handpiece, air/water syringe and ultrasonic scaler can be affected by microorganisms such as “bacteria, fungi and protozoa, which multiply fast and protect themselves with a polysaccharide slime layer (glycocalyx), spread to waterline tubing and then create a biofilm” (Centers for Disease Control and Prevention, 2003). The biofilm acts as reservoir for free-floating microorganism in water meant for dental procedures.

The dental department must be aware of these waterline challenges and develop standard procedures to ensure safety of patients.

It would follow the CDC guidelines that require dental waterlines to be flushed at the beginning of the clinic day to lessen the microbial load (Centers for Disease Control and Prevention, 2003). In addition, the department will ensure that all dental devices that link to the dental water system and used in “the patient’s mouth are discharged of water and air for a minimum of 30 seconds after every use on a patient” (Centers for Disease Control and Prevention, 2003). This would flush out any microorganisms within the system.

The dental department shall train all DHCPs about the water quality, formation of biofilm, best methods for treating water and effective maintenance procedures for water delivery channels.

It will work with manufacturers of dental water units to ensure maximum safety, best water quality and the necessary evaluation frequencies.

Sterile solutions will be used during oral surgical procedures to reduce risks and transmission of microorganism.

A boil-water advisory implies that the quality of public water has been “comprised and it therefore is necessary to boil it before consumption” (Centers for Disease Control and Prevention, 2003). During the advisory, DHCPs will not provide water to patients through “the dental unit, ultrasonic scaler, or other dental equipment that uses the public water system” (Centers for Disease Control and Prevention, 2003).

Dental Handpiece and Other Devices Attached to Air and Waterline

The CDC has identified several “semicritical dental devices get in contact with mucous membranes” (Centers for Disease Control and Prevention, 2003). They are usually connected to air and waterlines found in the dental unit. These devices consist of handpieces and other devices that may be contaminated through oral fluids during dental care procedures.

The dental department, therefore, will discharge water and air within these units for at least 30 seconds as recommended by the CDC. This approach would simply eliminate any materials that could have entered the lines (Centers for Disease Control and Prevention, 2003).

The dental department will use heat methods to sterilise certain dental handpieces and some intraoral equipment connected to air and waterlines (Centers for Disease Control and Prevention, 2003).

For any equipment that is visibly soiled, the DHCPs will clean and disinfect them with the EPA registered hospital disinfectants before they can be used on patients.

No adverse cases have been reported from saliva ejector. However, the dental department will develop a procedure to handle cases of backflows when they take place.

DHCPs will dry their films using disposable paper towels or gauze once they are exposed to radiography. This will remove any excess body fluids for efficient transportation. Any film barriers will be handled with optimal care to prevent possible contamination.

Central Sterile Supply Departments (CSSD) Unit

At the CSSD unit, the dental department will ensure that cleaning, decontamination, sterilisation, assembly and distribution of all dental surgical devices take place.

The unit will unite to prevent possible infections. The dental department unit would ensure that all items flow through a single channel for cleaning, decontamination, sterilisation and storage purposes.

Proper walls will be constructed to separate units for cleaning, decontamination, packaging, sterilisation and storage. In addition, the department will develop practices with simple procedures to follow to ensure that DHCPs contribute in reducing microorganisms in the dental department.

Only EPA recommended chemicals for hospitals would be used in the unit for cleaning, disinfecting and sterilising devices. These processes will be critical for the unit and therefore they will require optimal attention. Further, the unit will have to invest in modern equipment to ensure that devices are thoroughly and effectively cleaned and sterilised.

The dental department will handle cases associated with knowledge barrier or rather lack of knowledge through enhanced knowledge sharing, communication and training and education. Therefore, sharing critical knowledge to ensure safety in the CSSD unit will ensure that DHCPs understand staffing abilities, devices, working environments and related needs in the dental department.

Additional resources will be provided to meet unique needs of the CSSD unit. In addition, the unit will be encouraged to discuss its challenges with related stakeholders in order to enhance safety of the dental department.

Conclusion

The dental department that seeks for Joint Commission International (JCI) accreditation must meet specific safety procedures for preventing and controlling microorganisms that cause infectious diseases. In addition, it must manage healthcare professionals’ health and safety concerns when they interact with patients.

On this note, the dental department will adopt the best recommendation from the WHO and CDC, academics and other credible organisations. Occupational safety concerns for ensuring a safer dental practice environment is imperative. Continuous training and education and protection of both patients and DHCPs aim to limit exposures to deadly microorganisms that spread diseases.

The dental department must comply with various laws and regulations provided by federal, state and local authorities. Effective infection control and operation efficiencies demonstrate optimal compliance with various regulations.

Various procedures and standards covered in this report would therefore ensure that the dental department operates within the expected standards to deliver quality dental care in a safe environment and therefore can qualify for accreditation.

References

Agarwal, B., Singh, S. V., Bhansali, S., & Agarwal, S. (2012). Waste Management in Dental Office. Indian Journal of Community Medicine, 37(3), 201–202.

Boyce, R., & Mull, J. (2008). Complying with the Occupational Safety and Health Administration: guidelines for the dental office. Dental Clinics of North America, 52(3), 653-68, xi.

Canham, L. (2013). Hand Hygiene, Infection Control & CDC Guidelines. Web.

Centers for Disease Control and Prevention. (2003). Guidelines for Infection Control in Dental Health-Care Settings — 2003. MMWR, 52(RR-17), 1-48.

Centers for Disease Control and Prevention. (2008). Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention. Web.

East Carolina University. (2004). Equipment cleaning, disinfection and sterilization. Web.

Myers, R., Larson, E., Cheng, B., Schwartz, A., Silva, K. D., & Kunzel, C. (2008). Hand Hygiene Among General Practice Dentists : A Survey of Knowledge, Attitudes and Practices. The Journal of the American Dental Association, 139(7), 948–957.

Onana, J., & Ngongang, A. (2002). Hygiene and methods of decontamination, disinfection and sterilization in dental offices in Yaounde. Tropical Dental Journal, 25(97), 45-51.

Pine, P. (n.d). Break the chain of infection in your dental practice. RDH Magazine, 33(8), 1.

Samuel, R., Almedom, A., Hagos, G., Albin, S., & Mutungi, A. (2005). Promotion of handwashing as a measure of quality of care and prevention of hospital- acquired infections in Eritrea: The Keren study. African Health Sciences, 5(1), 4– 13.

Shimoji, S., Ishihama, K., Yamada, H., Okayama, M., Yasuda, K., Shibutani, T.,… Furusawa, K. (2010). Occupational safety among dental health-care workers. Advances in Medical Education and Practice,1, 41–47.

Thomas, M. V., Jarboe, G., & Frazer, R. Q. (2008). Regulatory compliance in the dental office. Dental Clinics of North America, 52(3), 629-39, x.

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