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Cleaning your knowledge: compliance and the dental team

Blog Author David Westgarth

Blog Date 15/08/2017


hand-washing-istock.jpg​​BDJ in Practice spoke to the Patron of the Society of British Dental Nurses, Fiona Ellwood, about what the last eight years have meant for the dental team in regards to compliance and regulatory issues:

In your view why was HTM 01-05 so significant?

Decontamination and infection prevention and control were always part of core training for dental professionals and particularly for the dental nurse; prior to the introduction of HTM 01-05, but when we look at significant developments and key changes, the publication of the requirements and the document went a long way in basing what we did and would do on better practice. It’s not too much of an exaggeration to suggest things changed forever – and for the better – at that point.

Dentistry is a fast-moving profession, so how often does HTM 01-05 get looked at?

It has been reviewed and the second edition was issued in 2013, but there were a number of amendments introduced before then. I’m led to believe the latest review of the standards should have already been published.

I do think it is important documents like this are reviewed frequently. We as dental professionals always look for what we do and how we do it to be evidence-based. The problem many practitioners found when it was first released was that some of the requirements were not always evidence­ based. Some of the amendments introduced over time, such as the storing and packaging of instruments, was done so on the basis of new information being presented.

So what was the biggest change pre and post HTM 01-05?

For me the answer is twofold. Decontamination and infection prevention and control standards in the community dental and hospital services were already structured and streamlined. Those working in general dental practice were operating their standards more by way of unwritten rules and what they considered to be the right thing to do. For those, the change was enormous.

Looking back those in hospitals and community dental services were probably better equipped than general dental practitioners and one-man practices who may have found it quite a challenging change. The workflow had to change and it had the potential to be costly – practice owners were expected to buy new equipment, for example. Timeframes had to change too.

For example the dental nurse who was already undertaking a large number of duties on top of caring for the patient had to add these extra measures to the list as well. For those with the revenue, they employed ‘decontamination assistants’, but the principle remained the same – it added time and cost, but with inferred better patient outcomes. It could be recognised by some as further financial outgoings not long after the economic crash in 2008. The structure, the flow, the consistency and the way we approached packaging and the continual monitoring were the biggest changes.

Fast forward eight years. That document is embedded. It’s now part of everyday life in practice, but what is the impact of those changes and developments?

If you talk to dental nurses involved in the work stream, if it has been part of  their training and they were born into the profession after 2009, they don’t know any different – it’s always been a part of their job. Those who were part of the change have adapted – because they had no choice – but they have adapted well. The challenge for many dental teams is now keeping their knowledge up to date. That’s proving to be more difficult than it sounds.

There are mixed messages on what you should/should not be using. Unfortunately we are increasingly seeing individuals and companies providing CPD from a sales perspective rather than theoretical and learning perspective. Throw in antibiotic stewardship and the need for a wider understanding of why those issues are important and there is a huge expectation on dental nurses and the entire dental team to understand the ‘why’ element.

What are some of these mixed messages?

Take the changing and use of gloves for example. There are different types of gloves for different  procedures, but the issue is more the use of cleaning agents such as hand washes and hand rubs between changing them. Some take the former as a replacement for the latter, and that is absolutely not best practice.

Where do these mixed messages originate?

There are a variety of sources, and that in itself is a problem. We have the guidance yet many professionals  interpret what is said in a number  of ways. As a Society we take  a great deal of guidance from one of our Fellows who specialises in oral microbiology for dentistry. We also have decontamination leads within the Society, and I am the co-programme lead on the infection control lead module on the foundation degree at the University of Chester.

Is that something you would recommend?

HTM 01-05 recommends you appoint a decontamination lead. Sadly we still hear about practitioners taking on the responsibility and juggling multiple expectations  rather  than delegating this to an identified lead. There isn’t really a group to share best practice with, so it’s done on an ad-hoc basis. Everyone draws from a different point of knowledge. This is a vital component of the Society as it helps keeps the membership informed and offers support.

Could HTM 01-05 go one step further than recommending one is appointed?

I believe that this role is essential if the dental team are to  be well  informed and are to exercise best working practice. Yes there would  be challenges with not only implementing the directive, but who would give it in the first place and who would monitor it in the long term. I firmly believe decontamination and infection prevention and control standards are so important for the dental team that this should be considered. Perhaps it could become at the very least a ‘notable practice’ consideration from the CQC.

So what should people looking for CPD in this area consider?

If I look at the courses out there, there is a criteria I would encourage people to look at before attending. Does it meet GDC standards? Does it meet CQC? Does it meet both? As with anything that is potentially product-driven, there will be an agenda behind it. This is such an important topic we have to look beyond that.

Find a competent and preferably qualified or trained lecturer/speaker who you feel comfortable with and believe has the knowledge to deliver the information  and who can award CPD and undertakes quality assurance  practice  along with  an intention to assess learning. NSK have developed some short courses which I have contributed towards and they were deliberately assessed against the GDC requirements, what the CQC says and what the current standards are and their quality assurance policy.

The Society has also developed an accreditation approval scheme so that dental nurses can easily see that CPD courses meet an expected and required standard. That’s quite an important point for not only dental nurses to consider, but for the principal dentist too. When registration was introduced for dental care professionals, dental nurses then had ownership of their professional position and an expectation of learning. No longer were dental nurses expected to turn  up, do their job and go home; they were expected to become involved as wider members of the dental team and of life-long learning.

You mentioned antimicrobial stewardship earlier. How does that play a role?

We are trying to keep dental nurses informed about effective infection prevention and control. We can reduce the risk of infections developing and spreading by educating those within the team responsible for decontamination and infection prevention and control, highlighting how these things start and identifying how we can break that chain. If they don’t understand what they’re doing, they won’t be in a position to participate in effective infection prevention and control.

Do you think extended roles within the dental team is a benefit?

Absolutely. Extended roles are a huge benefit. If you take the community dental services as an example, who have a decontamination lead, the person responsible undertakes the monitoring, auditing and competence checks as well as delivering training and updates to the teams. I go back to responsibility and accountability too. It can keep dental nurses motivated and help with staff retention.

I was chatting to a dental nurse not long ago who said she could earn more stacking shelves, this cannot be right –  it is far from a well-paid career and many are in the job because they care for people, but we should consider the true role of the dental nurse. Developing a dental nurse who is passionate about decontamination and infection prevention and control standards can be an asset to any dental setting.

Is there one point you want to emphasise when it comes to standards?

That’s simple! Not to assume everyone knows what they’re doing. It’s a funny thing to say given the level of qualifications and training needed to enter the  profession, but it’s a dangerous, but often a natural assumption to make. Sometimes we find the induction process is quite often poor, so the key thing is continual training to ensure you and the team are up to date. If registered dental nurses join the team or act as locus nurses, we should never assume they are trained to the same level or way of the practice. After all there are three different routes to the point of sterilisation outlined in HTM 01-05.

What do you consider to be good practice for an induction?

Whoever is named as the decontamination and infection prevention lead should spend time getting those new to the  practice up to speed with a standardised training procedure long before they start working. A model of not being thrown in at the deep end and escalating into poor working practice is a good way to approach it.

You always have to consider the implications of your working practice, the CQC and the standards set by the GDC – ‘patients have a right to be treated in a clean and safe environment’. Ask yourself; what would your team say about your procedures? What would your patients want to know? It may be useful to promote your decontamination lead in your practice reception or newsletter.

It was interesting to note the CQC report into dentistry was positive for infection control, but well-led was one area for improvement. For me, well-led crosses over into infection control. A well-led practice in the first instance puts in place a framework that has been developed with the team, it pre-empts potential happenings rather than fire fights and has the ability to deal with situations that arise when you don’t expect them. It also means they have processes and fail safes in place to ensure they don’t happen again. I’d consider this in the induction process too.

Note: An updated version of this article was published in the August 2017 edition of BDJ in Practice, clarifying some points from the previously published July 2017 article.

Achieving high standards in infection control: training course

Our training course, Achieving high standards in infection control, will equip you with the knowledge needed to prevent and control infections in your practice, following the current regulations and guidance. The next course takes place on Friday 8 September in London and includes five hours of CPD. BDA members can book at a discounted rate.

Essential decontamination certification

Our certification course is designed to provide participants with a thorough grounding in all aspects of dental decontamination, and is also broad enough to act as a comprehensive refresher course for those who already have some experience in this field. This certification is suitable for dentists, DCPs and decontamination assistants.