How does the dental team balance the need for contemporaneous records and, at the same time, maintain an effective standard of infection prevention and control?

Read this article to: 

• Learn how to maintain an effective standard of infection control in your approach to record keeping
• Discover where major infection risks can occur in paper and computer records

Very few clinicians have the luxury of dedicated secretarial support at the chairside while they are working on patients. Whatever your approach to record keeping, maintaining an effective standard of infection control should be paramount.

Maintaining the chain of sterility 

Have you ever stopped to think what happens when contaminated fingers touch the paper record card or hit the keys of the computer keyboard? There will certainly be a greater risk of disease transmission if the writing instrument or the writer’s fingers had been contaminated when the entry was made.

Operator-to-patient contact is one of the main methods of spreading bacteria but patient records handled by the dental team can also be the cause of cross contamination. Hand hygiene is essential if effective zoning is to be achieved. Periodic review by the dental team of adherence to this protocol is one method to ensure compliance.

Paper records

In order to create effective zoning within a clinical area, paper records need to be kept beyond the area of clinical activity. Since barrier protection is applied to the hands whilst treating patients, it means that additions to the record can only be made before gloving up or after they have been removed and the hands washed. If the need arises to add information to the record during the course of the treatment, there are three ways to deal with this:

• Remove gloves, wash hands or use approved alcohol-based hand rub (AHBR), add notes, and change into new gloves after having washed hands or used AHBR after adding to the notes.
• Create a second barrier (such as a loose fitting bag or disposable ‘mitt’) placing it over your gloved hand before writing.
• Another member of the team who is not gloved up could make the entry.

Silver papaer

Superbugs, including MRSA and clostridium difficile, pose a growing challenge. Items such as patient records and case note folders can now be impregnated with an additive containing silver ions, which instantly kills microbes on contact. This provides a permanent hygienic solution that is active 24 hours a day throughout the lifetime of the product. Clinical research conducted by one manufacturer showed that 99.9% of bacteria are killed within 24 hours. This approach will possibly become a required standard for the manufacture of record cards in the future, if we do not manage to go paperless.

Computer records

In many dental surgeries there has been an attempt to eliminate paper records and to replace them with a computer-based equivalent. From an infection control perspective, the use of a computer in the surgery reduces the number of items touched by the clinical team and, with suitable safeguards, it can be utilised within the zone of clinical activity.

The risks arise primarily from direct contact (for example, a contaminated gloved hand/finger) or via aerosols and splatters. The former can be managed by ensuring that there are strict hand hygiene protocols in place, while the latter can be reduced by appropriate surgery design and computer positioning.

Aerosols are inevitably created in the dental surgery when working in the patient’s mouth. Aerosols and droplets generated by high-speed dental drills, ultrasonic scalers and air/water syringes are contaminated with blood and bacteria and represent a potential route for transmitting disease. Pathogens can settle onto surfaces anywhere in the clinical environment. Keeping a computer in the surgery means the keyboard, the mouse and the monitor are vulnerable.

Key players

The average unprotected keyboard is a blackspot for bacteria, each 2.5cm squared harbouring a staggering 3,295 organisms. One study found potential pathogens cultured from computers included coagulase-negative staphylococci (100% of keyboards), diphtheroids (80%), Micrococcus species (72%), and Bacillus species (64%). Other pathogens cultured included ORSA (4% of keyboards), OSSA (4%), vancomycin-susceptible Enterococcus species (12%), and non-fermentative gram negative rods (36%). Particular bacteria hotspots are the space bar and vowel keys because they are most often used. 

Therefore, computer equipment should be covered with a plastic barrier when contamination is likely. This would apply primarily to the mouse and keyboard.

Like any barrier used during patient care, it should be changed between patients. If a reusable form-fitted barrier is used, it should be cleaned and disinfected between patients. The use of disinfectant wipes has also been advocated, but the potential to damage the plastic keyboard needs to be considered. Infection control keyboards that are capable of being washed are also available.

Strict hand hygiene is also important. Before touching any office equipment wear powder-free gloves or ensure your hands are clean. Computer equipment is an example of a clinical contact surface and the basic principles of cleaning and disinfection used routinely in the dental environment should also apply. Further comprehensive hand hygiene measures can be found at Hand Hygiene Australia (HHA): hha.org.au

Screen attraction

The risk posed by the computer screen is slightly different. Bacterial cells possess a negative electrical charge, while the technology used in flat screens generate positively charged static electric fields.

Consequently, bacteria dispersed within the aerosols will be attracted to the computer screen. Avoiding contamination of the unit housing the screen is important because it cannot be properly cleaned and disinfected or sterilised. Avoid touching the screen whilst treating patients, be aware of the potential bio-load on the screen and perform hand hygiene if you need to adjust the monitor with ungloved hands.

In addition to ensuring that your dental records are accurate, complete and contemporaneous, the infection control protocol within the clinical setting is also worthy of further consideration. The resources listed below are just a few of those used in this article.

Resources

1. Dr Philip Johnstone BChD MFGDP(UK)
2. Rutala WA, White MS, Gergen MF, Weber DJ; Bacterial contamination of keyboards: efficacy and functional impact of disinfectants. Infect Control Hosp Epidemiol 2006;27:372–377.
3. Bacterial contamination of computer touch screens, American Journal of Infection Control 44(3):358-360, March 2016, DOI: 10.1016/j.ajic.2015.10.013
4. Bacterial Contamination of Computer Keyboards in a Teaching Hospital, https://doi.org/10.1086/502200 Published online: 01 January 2015
5. Maureen Schultz, Janet Gill, Sabiha Zubairi, Ruth Huber, Microbial contamination of laptop/ keyboards in dental settings, Anjumn et al International Journal of Public Health Dentistry