There are so many protocols needed to ensure that your dental practice meets federal and state health regulations and American Dental Association recommendations. This article will address how and why we use checklists in our practices to prevent simple errors and ensure success in our complex clinical world.
For those of you who have recently opened a new practice or purchased an existing one with outdated protocols, having a system in place will make a big difference for your staff’s efficiency.
We must address the issues of safety and sterility with every patient, every day. It’s often when a practice is experiencing a big change, or a team member is transitioning to a different role, that the systems experience hiccups. Having a checklist in place prevents a lapse in a system’s success. People can lull themselves into skipping necessary steps. But your checklists will give you all the information you need to make sure a team member doesn’t have to wonder if something got done when it was supposed to.
Once I read the book “The Checklist Manifesto” by surgeon and New Yorker writer Dr. Atul Gawande, I redesigned my practice’s system. In the book, the author describes the necessity of checklists in the hospital and medical world. For my team and I, it reinforced a basic concept that often gets overlooked: without the actual checklist to reference, it often just doesn’t get done. It’s just human nature.
For the sake of simplicity, I have narrowed down the checklists to three:
- An Occupational Safety and Health Administration monthly checklist
- A monthly sterilization and solution report
- An emergency medical kit checklist
The ADA released its Practical Guide to OSHA Training” and infection control, which would be a huge help for you when setting protocols up in your practice. You should have a copy of this in your office. It can be purchased for $200, or for $135 if you’re an ADA member.
Cold sterilization solutions
The most common high-level cold sterilization solution is glutaraldehyde. Examples include procide, banicide, cidex plus and biocide. These solutions typically last 28 days once activated and, depending on the object placed in it, will require 3-6 hours immersion. Studies show that “disinfection” can occur, which means most microorganisms are killed (just not bacterial spores) within 15-30 minutes.
There are other non-glutaraldehyde solutions like cidex, metricide and rapicide — ortho-phthalaldehydes that have been cleared by the Food and Drug Administration for efficacy in the dental office.
The team member responsible for the solution should know that these containers need to be in a well-ventilated area and have a cover to prevent evaporation. When handling the solutions, wear your safety glasses and don’t pick instruments or objects out without putting on a pair of gloves. We now have more heat-tolerant plastics and disposable items, so the use of cold sterilizing solutions will be lessened in the future. Many practices have transitioned away from using cold sterilization altogether.
If you want to check the efficacy of your gluataraldehyde solutions, you can use Cidex plus strips. It’s a quick and easy way to check the concentration of the solution for its effectiveness. You would place the pad in the solution for the exact time that comes with the instructions. It could be one second, then remove it and stand it upright on a paper towel to blot the excess off. But do not shake it. It will read as a color code, kind of along the lines of a pregnancy test. My staff enjoys this system because it gives them a clear idea when to change it, if necessary, before the 28 days.
SteriChek strips or sterilizer monitoring for spores
These spore strips are impregnated with two different types of bacteria, both of which are highly resistant microorganisms. They are bacillus atrophaeus and geobacillus sterothermophilus. These organisms are on the spore strips because they are more resistant and present in greater numbers than the common microbial contaminants found on patient care equipment. So, if your sterilizer is inactivating these spores, it is working well for the more common bacterium you are trying to eliminate.
While every state may have its own regulations for frequency of testing, the CDC recommends testing it weekly. In the course of your busy week with many autoclaving cycles, and with some practices having two or three autoclaves, having a list to document when you test it can be so very helpful. If you receive a call that your test strip tested positive, repeat the test first and then remove your autoclave from service until it can be tested and repaired.
Ultrasonic cleaning solutions
Placing instruments in an ultrasonic cleaning solution prior to sterilization is a most routine practice in dental offices. The ultrasonic cleaning — also known as cavitation — removes debris, saliva and blood from the instruments. If this isn’t accomplished, the sterilization is not effective.
Some companies are adding enzymes to boost the cleaning properties. The enzymes (or proteins) act as catalysts to break down organic materials such as blood and saliva. These enzymes will be listed as amylase and protease and a solution may have both. They also may have rust inhibitors for your instruments.
These solutions should be changed daily, especially if they become cloudy or filled with debris. Don’t use your bare hands to drop instruments in and keep the cover on to contain the aerosol that will develop when the sonic action is on.
Since you are likely pouring this down your sink in the sterilization room, look for products that are low in phosphates or phosphate-free. It’s one way we can stay environmentally friendly.
First aid kit
The first aid kit is not the emergency medical kit. Its contents usually include alcohol wipes, Band-Aids, Neosporin, a thermometer, cold pack and burn gel.
I know it sounds simple, but just be sure you have Band-Aids and non-expired Neosporin.
Emergency medical kits
It is most critical that this kit gets its due attention because when you need to use it, you need the drugs to not be expired. Many prepared kits include drugs you will probably never use.
Many offices put together their own kits, which is certainly an accepted approach. But either way, it is a huge liability if you need a drug that has expired. It’s easy to have happen, for example, when the one team member that addressed it (who ordered the kit, stored it appropriately and maintained replacement of drugs when expired) leaves the practice.
It is easy to see how now no one takes responsibility for the emergency medical kit. Having it on your checklists will ensure that someone will address it. Some companies that sell emergency medical kits have an automatic refill service and ship the drugs when they expire. It is a great option for practices that don’t have a system in place to review expiration dates or that want security in knowing that when the date is approaching, the new drugs will be shipped.
The ADA has a list of the standard drugs you need to have in your medical kit. The seven core drugs are glucose, diphenhydramine-benadryl, nitroglycerin, albuterol, aspirin, epinephrine and oxygen. Every office should have these drugs and the drugs should be up to date. I encourage you to go check your kit today and see what has expired and get it replaced.
My assistant has taped to the kit a list of the contents and the expiration dates for each drug. This way it can be readily reviewed without having to open the kit and individually examine every drug.
Automated external defibrillator (AED)
I am referring to the two main portions: the pads and the battery. Hopefully you’ll never have to use this life-saving equipment, however, if you do, that battery must be functional. The life of the battery can vary depending on the manufacturer and most need to be replaced every 2-5 years. It’s critical to know when your date is approaching so that you have a new one in the office before it expires.
A study published in 2011 by the Journal of Emergency Medicine found that almost one in four AED failures was due to faulty batteries, which resulted in 1,150 deaths over a 15-year period.
The other portion of the AED that needs to be addressed for expiration is the yellow pad. These pads contain a gel that allows the pad to make full contact with the patient's skin. Over time, this gel dries out and hardens, making it less likely that the pad makes full skin contact. Using these expired pads may present a greater risk of failure in achieving the lifesaving results expected from an AED system.
Most dental practices use a fast, high intensity curing light. It shortens the amount of time needed for curing our composite resins, but it depends upon sufficient intensity and quality of the light.
This can be tested and should be a part of your checklist protocol. If the quality is less than adequate, the light-sensitive materials will not polymerize completely and in the long-term may be responsible for restoration failure.
Some of the factors that can reduce the light output include the aging of the bulb and the filter, damage of the light guide or fiber optic cable, a deposit of composite on the tip, or erosion of the tip due to sterilization. Most practitioners are unaware of the importance of routine monitoring, care and maintenance of curing lights. There are several radiometers available to test your composite curing lights to ensure that your light is giving the full cure to your restorations. Most of the new curing lights have a sensor built in for this monitoring so using a radiometer is only necessary on your older curing lights.
High- and low-speed handpieces
Do you know exactly how many handpieces exist in your office? Taking a daily tally at the end of your day will ensure that none of them were accidently thrown out.
It has happened in my office and creates an unwelcomed end-of-day stress. You then must start going through your garbage looking for it and as unpleasant as that is, you will hopefully recover it and not have to order a new one. The same holds true for your hygienist with the piezo tips. Accounting for all of these handpieces will ensure that a mistake hasn’t been made and an investment in a new one won’t be necessary.
Where chemicals and other hazardous materials are in use, the risk of an exposure is high and proper emergency equipment is key to protect your patients and you!
OSHA's requirements state that the eyewash station should be no more than 10 seconds from the area of exposure, so it’s important to have one in every treatment room where caustic chemicals are used. The requirements also state that it should be activated weekly to verify its proper operation. The valves should be operational in one second or less and be hands-free.
Most units will attach to your sink and be plumbed or gravity fed. There are personal eyewash units you can purchase to use as supplement to deliver an immediate flushing solution. These are used to support the flush and cannot be used as a substitute for the gravity fed ones.
Gluma is a desensitizing chemical commonly used in our restorative practices. It is composed of glutaraldehyde and Hema and if inadvertently splashed in the eye can cause severe irreversible eye injury. An unfortunate exposure requires 30 minutes of eye washing. Checking to be sure your eyewash station is functional at any time is critical for managing this type of injury if it should occur.
Protection from fire starts with making sure your fire extinguishers are ready to go. Extinguishers are the first line of defense, so it is important that they are properly tested and inspected. It is recommended to check the gauge for the pressure reading every 30 days.
There are many different types of fire extinguishers. Check which kind you have. The most widely used type is a dry chemical one. It interrupts the chemical reaction of a fire by putting up a barrier between the oxygen and the fuel source. Fire extinguishers are heavy, so be sure every team member practices picking one up and holding it to get an idea of the weight and the feel.
There is an expiration date on the tag attached to your fire extinguisher and these need to be inspected by the fire equipment specialist or the fire department. You just need to know when that date is approaching so that you can arrange for the fire equipment specialist to check it. A lapse in checking it could have deleterious consequences so be sure it is on one of your checklists.
Most dental practices have amalgam traps or separators installed with a canister that collects the amalgam. You may have a chairside trap or vacuum collection system.
Either way, the collection accumulates and must be contained until it is recycled. You can check with your city, county, or local waste authority for the proper disposal of your amalgam waste. Just be sure to have this on your checklist because if it’s out of sight, it might be out of mind and create a bigger problem if it is unable to function.
Compressors and pumps
Most compressors and pumps require oil and when these expensive necessary pieces of equipment fail, it’s a bad day in the office.
Check to be sure that the oil gauges are where they should be and note it on your checklist. This maintenance is just as necessary as your car, but unlike the convenient light that blinks when your automobile oil is low, many of our compressors don’t give alerts until it is too late. Giving a quick look and check that you completed this will help ensure there is no loss of function in what is probably the most important piece of dental equipment.
I realize that all of you complete most or some of these checks in your protocols. Having a checklist to reference and utilize just ensures that necessary maintenance procedures get completed.
If you design your own checklists, you can follow the recommendations in Dr. Gawande's “The Checklist Manifesto.” Be sure to have clear, concise objectives and have a title that reflects the objectives. Keep the format uncluttered and logical and simple. Keep it on one page and use a font large enough to be read easily. Lastly, trial the checklist with front line users and modify it as necessary.
Dentistry is a practice of high skill and performance and Dr. Gawande said it best when he stated that checklists instill a kind of discipline of higher performance. I am sure you can agree that implementing this in your practice will help you master clinical success.
Mary Anne Salcetti, D.D.S., P.C., (www.maryannesalcettidds.com) is a member of Spear Visiting Faculty and a contributor to Spear Digest.