CPD Focus: Cross-Infection Control

What are the basic principles

of preventing cross infection?
Infection control is an important part of an effective risk management programme to improve the
quality of patient care and the occupational health of staff. All dental nurses, according to Kathy Porter,
have a duty of care to their patients to ensure that infection control procedures are correctly followed

T
he basic standards on infection n Use of shields if giving mouth to mouth n Use of zoning techniques to prevent
control for healthcare workers, resuscitation contamination of unsterilisable items
known as Standard Precautions, n Routine covering of all skin wounds. n Safe storage of sterilized items.
were first introduced as The document outlined extra Standard Precautions should also
Universal Precautions in 1987 by the precautions to be taken in dentistry and be followed by any person that comes
Centre for Disease Control and Prevention stated that: into contact with contaminated items. It
(CDC) based in Atlanta USA. They were should also be remembered that some
initially issued as recommendations ‘Blood, saliva and gingival fluid from infectious diseases are more infectious
for the prevention of the spread of the ALL patients should be considered before they show external symptoms
human immunodeficiency virus (HIV). infective’ (CDC, 1987). therefore Standard Precautions must be
This document outlined precautions to be It went on to advocate the use of rubber followed for every patient that attends for
taken to protect both patients and health dam, high speed aspiration and outlined treatment.
care workers for the first time from the the correct positioning of the patient As well as implementing cleaning and
spread of infection. It emphasised that to reduce the generation of aerosols. It decontaminating processes there has been
these precautions must be consistently described the need for the sterilization of a growing number of disposable items
used for all patients irrespective of known handpieces, the need for the flushing of used in dental practice to ensure against
infectivity. It outlined the precautions that waterlines and the thorough and careful contamination. The use of disposable
should be taken: disinfection of all items to be sent to a items are an essential part of Standard
n Use of personal protective equipment laboratory. It was the first document to Precautions as long as they are disposed
(PPE), including gloves, masks, goggles advocate the covering of surfaces that of correctly, i.e. in clinical waste. This is
or face shields, gowns or disposable cannot be sterilized. being extended into the manufacture of
aprons The Universal Precautions were disposable instruments. Disposable items
n Effective and timely hand washing updated in 1996 and renamed Standard must only be used once and carry a symbol
n Prevention of needlestick injuries Precautions. It was felt that ‘universal’ to designate this fact (see Figure 1).
implied perfection and although

2
Kathy Porter was a senior dental comprehensive these precautions could
nurse (decontamination) at the not provide perfect protection.
Birmingham Dental Hospital and In 2003 the British Dental Association
an editorial board member for (BDA) updated the Standard Precautions
the Dental Nursing Journal until and made them more relevant to current
retiring in March 2011. dental practice to include:
This article has been published as n The use of PPE Figure 1. Symbol denoting single use item
an extract from the book, Dental n Effective hand washing
Nurse Survival Guide: Common n Safe disposal of sharps You should never use an item marked
Questions and Answers for the n Safe disposal of clinical waste with this symbol on a second occasion
Dental Nurse, authored by Kathy n Effective hard surface decontamination and they should not be sterilized. There
Porter and published by Quay
n Effective decontamination and are some products marked with this
Books in 2011.
sterilization of contaminated items symbol which can be sterilized prior to

638  Dental Nursing November 2011 Vol 7 No 11

 CPD Focus: Cross-Infection Control

use and thrown away after use. Such items and every dental institution in 2008. This regulations, all of which are regularly
are fine bore aspirator tips that may be self assessment tool was devised by The reviewed and revised. It is imperative
used in a surgical procedure and are not Infection Prevention Society (IPS) and is that you, or someone in your practice,
supplied in a sterile state. However sterile updated regularly. It provides an invaluable keeps an eye on these changes because
narrow bore aspirators are available and tool in assessing how compliant your any breaches of their regulations could
should be the product of choice. practice is with the new regulations. It is the have severe consequences as these are
The Medicines and Healthcare Products tool used by auditors who visit to carry out enforceable by law. The following is a
Regulatory Agency (MHRA) regularly the audit required by the HTM 01-05. brief summary of the more important
publishes guidance and updates on the The HTM 01-05 also sets out Essential pieces of legislation:
use of medical devices (instruments, etc). Quality Requirements (EQR) which are the
The dentist should receive notification of standards that should be complied with 1. The Health and Safety at
these alerts. They are published if there are now and Best Practice (BP) which are the Work Act 1974
a large number of failures of a particular standards which must be achieved in the This Act sets out a framework that
medical device where users need to be future. Failure to meet the standards set places a duty of care upon employers and
aware of potential problems. The dental out in EQR could mean that a practice employees to promote high standards in
nurse needs to be informed if the alert is closed until improvements are made. the workplace as well as protecting the
gives advice as to the decontamination of a Written plans on how the practice will public from workplace dangers.
device or other restrictions in its use. The achieve BP must be in place when the
dentist is also duty bound to report to the practice is audited. 2. Management of Health and
MHRA any failure of a medical device, i.e. Safety at Work Regulations
if an instrument breaks it must be retained What legal obligations do 1999
and the breakage reported to the MHRA, I have? These regulations take into law the
so that the MHRA can investigate if there Even though you are not responsible, requirements of the European Union
are a large number of breakages of that legally, for what happens in the practice, directives which address issues of training,
particular item. you should be aware of the laws that have risk assessment and development of health
The BDA also published the Infection been enacted to protect your patients, your and safety policies. Further additions to
Control in Dentistry Advice Sheet A12 in colleagues and yourself from healthcare- the regulations required employers to
2003 which gave dental practices detailed acquired infections (HCAI). put in place preventative and protective
advice on how to follow these Standard The primary legislation setting out basic measures and made it possible for an
Precautions. This outlined specific rules for all healthcare establishments is employer to be prosecuted for the actions
precautions which had to be followed for The Health Act 2006 (DoH). It relates to of an employee.
patients with known infections such as: the provision of healthcare directly by NHS
n Prior contaminations (Creutzfeldt- organizations and is presented under three 3. Control of Substances
Jakob Disease (CJD) and variant headings: Hazardous to Health 1988
Creutzfeldt-Jakob Disease (vCJD)) 1. NHS organizations have a general (COSHH)
n Airborne transmissable diseases duty of care ensuring that appropriate These are regulations designed to prevent
(tuberculosis) management systems are in place to substances used in the workplace from
n Droplet transmissable diseases (mumps, protect patients, staff and others from causing harm to people working with
influenza) HCAIs. them or patients being treated using them.
n Transmission by direct or indirect 2. Relates to clinical procedures placing a It requires that all and any substances have
contact with dried skin (Colonisation duty of care on NHS organizations to a risk assessment carried out before they
by MRSA or contaminated surfaces). adhere to care policies applicable to the are used and that these assessments are
This advice booklet was superseded by prevention and control of HCAIs written recorded and revised regularly.
the Health Technical Memorandum 01-05 3. NHS organizations have a duty to ensure The assessment should include maximum
(HTM 01-05) which was introduced by as far as possible that healthcare workers safe exposure limits and any first aid and
the Department of Health in 2008. The are free of, and protected from, exposure follow up treatments that are required if
HTM 01-05 is now the document of to communicable infections during the exposure occurs.
choice to consult on all areas concerned course of their work. They must also
with infection prevention and control and have the necessary education to prevent 4. Environmental Protection
decontamination. A self-assessment tool and control HCAIs. Act (1990)
was also supplied with the hard copies of Working in a dental practice, you are This Act sets out the legal guidelines for
the document when it was supplied to each also bound by certain other laws and the safe disposal of waste in all forms,

Dental Nursing November 2011 Vol 7 No 11 639

 CPD Focus: Cross-Infection Control

especially contaminated waste and clinical out with these expenses or may have an This also protects healthcare workers and
waste. It also sets out rules for the safe arrangement with a local GP but if they subsequent patients from infection from
disposal of substances such as mercury don’t you will have to cover the cost a patient who does not declare or does
and amalgam. yourself. This should not be an excuse for not know that they have or are carrying
Many of the requirements set out not maintaining your protection levels. an infection.
in these acts of legislation are brought Apart from ensuring that your
together with other guidelines and What should I do immunity is up to date and appropriate,
standards in the HTM 01-05. to protect myself? and that both you and your establishment
You must have your immunity levels follow Standard Precautions, you should
What are the common checked regularly and booster injections also use PPE and ensure that you
arranged should your immunity be in follow effective hand hygiene regimes
infections I need to doubt. This will involve having a blood throughout all aspects of your work.
protect against? test which should be arranged through Other considerations for your
It is imperative that you protect yourself your local OHD who will give advice on protection include:
against the many infections that are the best course of action after the results n Wear low heeled or flat shoes that cover
carried by patients, other staff, visitors are known. the whole of the front of the foot
or escorts. All dental nurses must be It is possible for some people to not n Hair should be tied back so that it cannot
vaccinated against blood borne viruses, gain immunity after a course of hepatitis B fall over the face during chairside work.
the main one being hepatitis B. This injections. This does not preclude you n Any religious headwear should be
is currently the only hepatitis variant from working at the chairside but you washed daily and tied in such a way as
that can be vaccinated against. The other must take extra care and be scrupulous in to not interfere with chairside duties.
major consideration is HIV/AIDS but your adherence to Standard Precautions.
there is, as yet, no vaccination available It is almost impossible to protect What personal protective
against this. yourself completely against infections that
These are the most notorious infections may be brought in by patients or their
equipment should I use?
that are of concern to dental professionals escorts. Patients will not know if they are There are certain basic items of PPE
and it is essential that all dental nurses incubating infections, they may not feel that you should routinely wear at the
are vaccinated against hepatitis B and that ill or show any visible signs such as spots chairside and others that you should
your immunity level is regularly checked or rashes. It becomes imperative that use for cleaning, decontamination and
and boosted if necessary. Standard Precautions are scrupulously sterilization duties. These are outlined
Other infections which are beginning adhered to for every patient that attends. below.
to become more prevalent are measles, It is also important that other public areas
mumps, rubella and tuberculosis. These such as waiting rooms or toilets are also Chairside working
are infections that can be avoided by kept scrupulously clean. 1. Examination gloves
vaccination but the uptake of vaccination The main demand of Standard These must be well fitted to allow tactile
for children has fallen off significantly Precautions is that every patient must efficiency. They should also have a
following adverse publicity about possible be treated in the same way to satisfy roughened surface on the finger tips.
side effects. the requirements of discrimination Ideally they should be latex free but
Many of these infections are at their legislation. When HIV/AIDS was should not be made of vinyl. Vinyl
most contagious before the visible signs first identified many extreme special gloves do not offer sufficient protection
or symptoms are apparent. Reasonable precautions were taken when treating at chair-side. It is imperative that the
precautions to protect yourself against known sufferers to protect healthcare gloves you use routinely fit very well
this possible threat are essential and workers and subsequent patients. This to allow manual dexterity and tactile
advice about boosters and immunity was deemed as discriminatory and sensitivity. The gloves must be changed
levels sought from either your general Universal/Standard Precautions were between patients and must be removed
medical practitioner (GMP) or your devised to ensure that cross infection before touching any item that cannot
local occupational health department could be minimized or removed but no be decontaminated effectively, if they
(OHD). You are responsible primarily patient would be treated in a different are contaminated. They must never be
for protecting yourself. This may come manner because of their known or washed or sanitized with alcohol gel.
at a monetary cost as some GPs will unknown infectivity. Hence every patient Sterile gloves in individual sizes and
charge for these injections. The practice should be treated in the same way and packed in single pairs must be worn for
you work for may be willing to help regarded as being potentially infectious. surgical procedures.

640  Dental Nursing November 2011 Vol 7 No 11

 CPD Focus: Cross-Infection Control

2. Face masks to protect your uniform. Your uniform such as suction tubings. They are not
Face masks protect you from inhaling should not be worn outside the practice, usually necessary when carrying out
contaminated aerosols. There are but a disposable apron or gown will general cleaning or taking items from the
many types available but the minimum reduce the amount of contamination on sterilizer although they could be worn if
standard must be that the mask is type your uniform. Some type of disposable you feel it necessary.
II filtration and water repellent. It is cover should be worn whenever there is
possible to buy masks which have an the possibility of blood contamination, 3. Eye protection
integral microbial filter which give i.e. during surgical procedures, Essential when carrying out
increased protection. However this type extractions, deep scaling etc. As with decontamination of equipment or
of mask is more expensive. This type other PPE, these gowns or aprons must instruments but not essential when for
II filtration mask is not adequate for be disposed of between patients and general cleaning or removing items from
protection if treating a known ‘swine flu’ must never be worn from one patient the sterilizer.
case, when a specifically fitted respirator to another.
mask must be worn. Some masks have 4. Disposable aprons or gowns
integral eye protection but users must Decontamination, sterilising These should be worn for decontamination
ensure adequate protection is achieved. and cleaning and general cleaning but not for removing
If these are used it is also possible to 1. Examination gloves items from the sterilizer.
purchase face visors but these do not For cleaning and decontamination, heavy
give adequate aerosol protection and a duty gloves must be worn, which are How do I ensure I
mask should be worn as well. Whatever washed and dried after use and disposed
type of protective mask / visor is used, it of regularly. Examination gloves should
effectively wash my
must be changed between patients. Paper be worn when removing items from the hands?
masks must be thrown away. Visors which autoclave and bagging. There is a recognised eight-stage process
are not disposable should be disinfected for ensuring effective hand hygiene as
or decontaminated according to the 2. Face masks shown in Figure 2.
manufacturer’s instructions. Should be worn during decontamination It is possible that the Infection Control
procedures and cleaning of equipment Team (ICT) at your local Primary Care
3. Eye protection
This is essential to protect the eyes from
the aerosol created during treatment.
Wash hands using the following 8 steps
Apart from microscopic blood particle, it
Each step consists of five strokes rubbing backwards and forwards
will also contain tooth debris or calculus.
Apart from the aerosol, other particles can 1. Wet hands under 2. Work into hands,
running water. Take palm to palm
be expelled from the mouth during cavity a measure of soap
preparation or scaling. Eye protection
should, ideally, be close fitting and wrap
around to protect effectively. If you wear 3. Right hand over 4. Rub palm to
back of left and palm, fingers
prescription glasses routinely, then, vice versa interlaced
depending on the size of the lenses, you
may need to wear wrap around protective
glasses over the top. Whatever type of eye 5. Back of left 6. Rotational rubbing
protection is used it must be thoroughly fingers to right palm, of right thumb
fingers interlocked clasped in left hand
decontaminated between patients, if it and vice versa and vice versa
is not disposable or capable of being
sterilised. It is also imperative that the eye 7. Rub left palm with 8. Left wrist
protection you use is suitable for you. It clasped fingers of right with right hand
hand and vice versa and vice versa
cannot be a case of ‘one size fits all’ in the
practice.
Rinse hands under running water and dry thoroughly

4. Uniform protection
It is becoming more usual for some type
of disposable gown or apron to be worn Figure 2. Hand washing procedure

Dental Nursing November 2011 Vol 7 No 11 641

 CPD Focus: Cross-Infection Control

Trust (PCT) may be able to come into can be achieved: gets into an open wound, could lead to
your practice to demonstrate an effective n Keep nails short, no nail extensions, and an infection and mean that you cannot
procedure and test your technique using free from varnish or polish or other nail work until it is clear.
an ultra violet light box. adornments
It is a good idea to have a copy of the n Do not wear a wrist watch What should I do if I
procedure presented in Figure 2 fixed by n Only wear a plain wedding band, have a ‘sharps’ injury?
every hand wash sink. It is also essential no costume or stoned rings. Any A sharps injury is any injury caused
that sinks are designated as either ‘Hand engagement rings or stoned wedding by a sharp, contaminated instrument.
wash only’ or ‘Decontamination only’. It bands should be covered with tape if This includes used needles, used burs,
is imperative that the distinction is made they cannot be removed used matrix bands, airscaler tips or
and decontamination is not carried out in n Wear short sleeves and have disposable other sharp instruments. It can also
the same sink as hands are washed. arm covers if sleeves cannot be short for include splashes into the mouth or eyes
religious reasons from contaminated liquids or bites from
When should I wash n Do not wear any wrist adornments. patients.
my hands? Friendship or religious wrist ornaments You must take any such injury very
There are some essential times when you should be pushed up the arm and seriously. It is this type of injury that
should follow the hand wash protocol but covered with tape. can put you at risk of contacting a
it would be better if you get used to always blood-borne infection. If you sustain
using an effective hand wash technique. It Is my personal hygiene an injury from a contaminated ‘sharps’
will become second nature in just the same important? you should:
way as basic aspects of your day to day It is important that your personal hygiene 1. Wash the wound and make it bleed, if
job. You should also be aware that this is is impeccable to protect yourself and others possible
important at home as well as at work. in your family. You should shower or take 2. Apply a waterproof dressing
In general, you should wash your hands: a bath daily and wash your hair as often 3. Check the patient’s medical history to
as possible. see if they have a known infection
1. At work You have taken many precautions to 4. Report in the practice accident book
n After you have used the toilet protect yourself in the workplace but and to the senior nurse or practice
n When you first enter the treatment area the aerosol created during treatment manager
n Before putting on gloves will contaminate you and everything 5. Inform the OHD that you deal with to
n After changing from heavy duty to you wear as well as your skin, so have your immunity level checked
examination gloves personal hygiene and effective laundry 6. If there is a doubt about a patient’s
n After taking off gloves techniques are imperative. medical history then you should
n After removing PPE It is almost inevitable that you will report to the local accident and
n When you leave the treatment area. find that your hands will become dry emergency department (A&E) for
because of the number of times you expert medical advice and possible
2. At home will wash them, so careful drying and blood tests. Details of the patient’s
n After using the toilet the use of a good hand cream as often medical history should accompany
n After changing a nappy as possible is essential. It is possible to you to A&E
n After cleaning up vomit, faeces or urine reduce the amount of times you wash 7. If the patient has a known blood-
n After handling pets your hands by the use of alcohol gels borne infection then immediate
n Before handling food or hand sanitizers. These must not be transfer to A and E is essential.
n When preparing food between handling used in place of washing but only if the If you work in a large establishment
raw and cooked food and between hands are visibly clean. Constant use such as a hospital or in the Personal
preparing meat or vegetables will leave a film on the hands which Dental Service, there will be an agreed
n After finishing cleaning. will encourage bacteria and not help protocol to follow which may involve
the condition of the skin on your hands. taking blood samples from both donor
How else can I ensure I It is important to keep any scratches (patient) and recipient (you).
or abrasions covered with a waterproof If you are splashed in the eyes or
carry out effective hand dressing before putting on gloves, if mouth you should wash the areas with
hygiene? they are on your hands, and covered copious amounts of clean, preferably
There are other rules that should govern if on the arms. The aerosol that is sterile, water. It is important that
your dress to ensure effective hand hygiene produced contains bacteria which, if it eyes are flushed very thoroughly and

642  Dental Nursing November 2011 Vol 7 No 11

 CPD Focus: Cross-Infection Control

put a patient at risk. This is part of your

responsibility as a registered dental care
Key points professional.
Cross infection is the transmission of pathogenic micro-organisms
„„ The PPE that is provided for your use
from one person to another. must be appropriate and adequate for your
needs. This is also a legal requirement
The job of cross infection control concerns all dental staff.
„„ under the Personal Protective Equipment
All measures possible are to be followed by dental staff in order
„„ at Work Regulations 1992. If the PPE
to control cross infection within the dental surgery. is not adequate and appropriate then
the practice owner is liable under these
To prevent cross infection the harmful micro-organisms must be
„„ regulations.
killed. The correct PPE must not be governed
by the cost but by its adequacy and
if any doubt about whether there is responsibility to protect themselves so appropriateness. It must fit well, be of the
any debris in the eye, then you should that no-one person puts the others at risk correct type and be fit for purpose.
seek immediate medical advice. An by their actions. A more detailed description of infection
antiseptic mouthwash could be taken Your employer has a duty of care to control and decontamination and your
after rinsing with water. make the working environment as safe as role and responsibilities can be found
If you receive a bite from a patient, then is reasonably practical, under the Health in the book The Dental Nurses Guide to
the sharps injury procedure described and Safety at Work Act 1974. You also Infection Control and Decontamination
above should be followed. have a similar duty of care to work in a (Porter K 2008). DN
way that does not put others at risk.
Who else can I rely on to It is also the case that if you are
protect me? expected to use gloves on more than British Dental Association (2003) Advice Sheet A12
– Infection Control in General Dental Practice.
Basically you must take all sensible one patient or are expected to reuse any BDA, London
precautions to protect yourself and that single use or disposable item or are not Department of Health (2008) Health Technical
must be your responsibility. You cannot allowed to use appropriate and effective Memorandum 01-05 – Decontamination in
Primary Dental Care. DH, London
rely on anyone else to protect you, PPE, then you must report it. If the
Porter K (2008) The Dental Nurses Guide to Infection
however, as part of a team, you should situation does not improve then it must Control and Decontamination. Quay Books,
make sure that all team members take be reported to the GDC because it could London

Dental Nursing November 2011 Vol 7 No 11 643

Copyright of Dental Nursing is the property of Mark Allen Publishing Ltd and its content may not be copied or
emailed to multiple sites or posted to a listserv without the copyright holder's express written permission.
However, users may print, download, or email articles for individual use.