First Impressions

Infection Control

By Laura Thill

The look and feel of the reception area is important, but keeping it free of germs and infection is critical to the health of patients and staff.

The dental reception area is the initial point of reference for patients, who expect a clean, welcoming environment that attests to the professionalism of the practice. Anything less may make them think twice about returning, according to Lean Keefer, RDH, BS, MSM, director of clinical services and education, Crosstex, A Cantel Medical Company. “We never get a second chance to make that first impression,” she points out.

“The appearance of the reception area reflects the attitude and habits of the dentists and staff,” says Keefer. “It’s critical to make a positive, lasting impression. In addition, the reception area should be designed to optimize patients’ mood and well-being, as well as improve their perception and experience.” Patients are reported to comment more frequently on their experience in the reception area than on the dental team’s clinical skills, she adds. “Clinical care and staff/patient relationships are key to having patients return, but don’t underestimate the power of how the dental office presents itself to patients.”

Achieving the ideal look and feel of the reception area is only half the battle. Upper respiratory and seasonal illnesses are easily spread, making it imperative for the dental staff to follow regular infection control protocols. “Upper respiratory and seasonal illnesses can be spread through direct contact with mucous membrane; cross-contamination with clinical contact surfaces; and droplet transmission, including sneezing and coughing, which spreads the pathogens by large particle droplets that carry microorganisms,” says Keefer.

“People with flu can spread it to others up to about six feet away,” she continues. “Most experts think that flu viruses spread mainly by droplets made when people with flu cough, sneeze or talk. These droplets can land in the mouths or noses of people who are nearby, or possibly be inhaled into the lungs. Less often, a person might get flu by touching a surface or object that has flu virus on it, and then touching their own mouth, nose or eyes.” (https://www.cdc.gov/flu/about/disease/spread.htm)

People often misread their seasonal illnesses, Keefer continues. For instance, a sick person can be contagious before his or her symptoms appear. “If you have a cold, you’re contagious for one or two days before your symptoms develop and for two weeks after you are first exposed to the virus,” she says. “With the flu, people are the most contagious in the first three to four days after symptoms begin. However, it is possible to infect others a day before symptoms start. Children and those with weakened immune systems may pass the virus for longer than seven days.”

First lines of defense
The reception area receives heavy traffic, from early morning to evening. If left unattended, it inevitably will become cluttered with waste and carry the potential for cross-contamination, notes Keefer, who recommends daily cleaning and maintenance, with emergency cleanups throughout the day as needed. “The staff shouldn’t ignore details that can differentiate the practice,” she explains. “They should take 10 minutes to sit down and carefully view the reception area through the eyes of a patient.

“Boxes of facial tissues and pump bottles of alcohol-based hand rub should be appropriately placed for patient use in the reception area,” Keefer continues. “Wastebaskets with lids should be positioned for easy access to avoid used tissues being left on tabletops or hidden under chairs.” It’s also important to account for patient demographics when selecting and arranging furniture, she points out. “Given that some patients value their privacy and are concerned about other people’s germs, it’s better to arrange small groupings of chairs than line them up along the perimeter of the room.”

Posting respiratory etiquette and hand hygiene signs in the reception area can serve to remind patients to cover their coughs and wash their hands, she says, noting that posters may be downloaded from the following websites:

• http://www.health.state.mn.us/divs/idepc/dtopics/infectioncontrol/cover/
• http://www.health.state.mn.us/handhygiene/how/clean8.pdf

How clean is that surface?

Cold viruses have been shown to survive on surfaces for several days, while flu viruses are capable of being transferred to hands and causing an infection that can survive on hard surfaces for 24 hours.

The staphylococcus aureus bacteria that cause MRSA infections can survive for days to weeks on surfaces. MRSA bacteria can live on surfaces for longer than some other bacteria and viruses because they survive better without moisture. Generally, MRSA bacteria survive for longer on hard surfaces than on soft surfaces. Germs generally remain active longer on stainless steel, plastic and similar hard surfaces than on fabric and other soft surfaces. Other factors, such as the amount of virus deposited on a surface and the temperature and humidity of the environment, can also affect how long cold and flu germs stay active outside the body.

The dental staff should follow surface disinfection protocol for housekeeping surfaces using the appropriate chemical/cleaner and process with dwell time. That said, they should be mindful, as strong cleaning solutions used to kill germs can cause respiratory problems. They should wear appropriate personal protective equipment (PPE) during cleaning and maintenance, including a Level 1 ASTM face mask, safety eye protection and heavy-duty utility gloves, says Keefer. “PPE must be donned/doffed appropriately, and hand hygiene should be performed immediately after doffing PPE.”

It’s important to take a consistent, organized approach, she says. “Cleaning from high to low, and back to front, helps avoid dust and debris falling back onto the surface,” she explains. “Durable, washable surfaces – including both healthcare grade and those manufactured for commercial use – are easier to clean. Clean first, then use an appropriate level of sanitizer or disinfectant as indicated, based on the surface being treated. (The friction of cleaning removes most germs, leaving remaining germs to be addressed by the sanitizer or disinfectant.)

“Sanitizing reduces germs on inanimate surfaces to levels considered safe by public health codes or regulations,” says Keefer. “Disinfecting destroys or inactivates most germs on inanimate objects, with the exception of bacterial spores and prions. It is important to follow the manufacturer’s instructions for use and maintain the safety data sheet binder for any cleaning materials or products used in the office.

Microfiber cloths and flat mop heads are recommended due to their ability to pick up and hold dirt, as well as efficiently absorb liquid, notes Keefer. “The absorbency of microfiber is up to seven times its own weight in liquid, which is great for cleaning spills or glass surfaces, without leaving streaks.” It can be helpful to keep color-coded, microfiber cloths on hand for each purpose, she adds. “Using machine washable microfiber cloths can help cut the cost of disposable cleaning products, such as paper towels. By folding the microfiber cloth into thirds lengthwise, and then again in half provides, multiple clean surfaces during cleaning and dusting. And, it’s better to spray a cleaning/disinfecting product directly onto the cloth as opposed to the surface to reduce aerosol and respiratory hazards. In addition, she recommends adhering to the following protocols:

• Windows, doors, walls and mirrors. All floors, walls, surfaces, cabinets, drawers, and equipment must be capable of being quickly and easily cleaned and disinfected. Using a microfiber cloth, damp wipe vertical surfaces and ledges, paying particular attention to smudges and fingerprints; use a cleaning agent as needed.
• High Touch Surfaces. This includes – but is not limited to – door handles, cabinet knobs, light switches, remote controls, phones and sink faucets, which should be cleaned and disinfected daily with an EPA-approved disinfectant. If high-touch surfaces become visibly dirty, they should be immediately cleaned and disinfected.
• Regular vacuuming of upholstered items can refresh the fabric and keep furniture looking good. The dental staff should spot clean any fabric and use appropriate solutions for vinyl and leather surfaces. They should dust light bulbs and replace burned-out bulbs. Using plug protectors in electrical outlets help keep younger patients’ fingers safe.
• Tables and wood. All wood trim on furniture and tables should be dusted. A mixture of a cup of olive oil and a quarter-cup of white vinegar can nourish the wood and help it retain its shine. Plus, the vinegar is a natural germ killer. In addition, the furniture legs, the front of the reception desk and other surfaces should be scrubbed.
• Interactive toys. Toys, games and play equipment can be easily wiped clean. It’s helpful to limit toys to those that are washable, with fewer parts and smooth/flat surfaces. Colorfast, plastic toys can be disinfected using a solution of a ½ cup of bleach per gallon of water. Toys should be soaked for five minutes, then rinsed and air dried.
• Electronic equipment. Televisions, monitors and cords should be wiped with a dry microfiber cloth approved for electronics and no-scratch surfaces. The entire surface of remote controls, keyboards and mouse pads should be wiped. It’s particularly important to address buttons, which are a source of cross contamination. Alternatively, single-use disposable surface barriers may be used to protect electronics.
• Trash and Recycle Containers. Loose trash should be picked up throughout the day and properly disposed of. When checking the trash bin for emptying, staff should refrain from reaching into, or pushing on, the trash liner to compress the trash. Rather, they should leave the liner in container, close the top, and twist and tie a knot in the top of the bag. (When disposing of the trash bag, it should be carried away from one’s body.) All surfaces of the trash container should be wiped down with a surface disinfectant wipe and allowed to air dry before replacing it with a new liner.
• Carpets should be vacuumed daily using a HEPA filter, low decibel vacuum cleaner. They should be spot cleaned as needed, and cleaned every three months. Hard flooring should be cleaned using a broom or dust mop, followed by flat-head mop for light cleaning.
• Odors can be particularly offensive to patients and staff. A good ventilation system with charcoal filters can help minimize unpleasant odors. Cautionary use of disinfectant/deodorant sprays is recommended, as patients may be allergic or have respiratory concerns.

Throughout the day, the dental staff should practice proper hand hygiene. Washing hands with soap and water is the best way to get rid of germs. If soap and water are not available, an alcohol-based hand sanitizer (minimum 60 percent) is recommended. The staff should offer respiratory prevention packets (i.e., a disposable surgical mask, facial tissues and cleansing wipes) to all symptomatic patients. And, they should attempt to isolate all patients with suspected illnesses.

Loose items should be kept organized in containers, office policies should be saved in plastic sleeves in a three-ring binder, and magazines and pamphlets should be stored in clear plexiglas holders and wall mounts to keep them orderly. “While studies have shown low fomite contamination of the glossy pages, some offices are removing magazines from the reception area and asking patients to bring their own reading materials and children’s toys to reduce the risk of cross contamination,” says Keefer.

Infection prevention resources

Additional information related to respiratory hygiene/cough etiquette can be found in the 2007 Guideline for Isolation Precautions (available at: http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf). Recommendations for preventing the spread of influenza are available at: http://www.cdc.gov/flu/professionals/infectioncontrol/.