EVALUATION OF CROSS INFECTION CONTROL PROCEDURES AT THE FACULTY OF ODONTOSTOMATOLOGY IN PHNOM PENH 

 

 

 

                              Faculty of Odontostomatology in Phnom Penh

Guillemette Clapeau / Dominique Roux / François Courtel (AOI)    February 2002

 

 

 

 

TABLE OF CONTENTS

 

 

1 Introduction

2 Method

3 Results

4 Recommendations

 

Appendix :

-          tables used for the evaluation

-          recommendations for a central sterilisation area

 

 

 

1 . INTRODUCTION

 

 

In a region where blood-borne viruses are common (HIV, Hepatitis), the prevention of cross-infections in dental facilities becomes imperative in Cambodia.

 

The Faculty of Odontostomatology in Phnom Penh is the training center for Cambodian dentists, and must demonstrate the best standards for cross infection control.

Despite many improvements since the reopening of the Faculty, it seems that the international standards for infection control have not yet been reached.

 

AOI has been present in Cambodia since 1998, and has provided support in the dental field in the following areas: prevention, improvement of the access to dental care, improvement of undergraduate training, and continuing education for dental personnel.

 

Guillemette CLAPEAU (Head Pharmacist – Longjumeau Hospital) and the Dr Dominique Roux (Ph.D, Lecturer, Faculty of Clermont-ferrand) previously visited Cambodia in 1999 and 2000 to conduct  short courses at the Faculty and in dental clinics supported by AOI.

 

Following these contacts with the stakeholders in the Faculty, a common will to improve cross infection training and practice was born..

 

It appeared important to do an evaluation of the infection control procedures before making any definitive recommendations.

 

 

Objectives: 

 

 

-             Evaluation of cross infection control procedures in the Faculty of Odonstomatology in Phnom Penh

-             Writing and discussing recommendations

 

 

 

 

2 . METHOD

 

 

The evaluation was prepared upstream by the Dr Suorn Phany (Dean) and

Dr François Courtel (AOI Cambodia).  G. Clapeau and D. Roux also participated

in the clarification of the program and objectives from France.

 

The method:

 

·     Visit to the Faculty of Odontostomatology of Phnom Penh

Discussions on the method and the program.

Short visit to the services.

Elaboration of the grid for the evaluation.

 

·     Evaluation of the infection control procedures in the Faculty: visit in the clinic during one morning using the grid presented in appendix 1.

 

·     Presentation of the analysis: Participative approach: analysis of the results by the evaluators and stakeholders of the Faculty.

 

·     Discussions and recommendations

 

 

 

3 . RESULTS

 

 

The cross infection control procedures at the Faculty are at 52% of the optimal level.

 

 

 

See in appendix 1 for the details regarding the grid used for the evaluation.

Please note that the clinics are not identified individually, as it appeared more acceptable to the evaluators to present a general view of the Faculty.

 

 

Following pages  :  the results of the analysis.

 

 

 

 

 

 

Strong points 

Analysis from  G. Clapeau and D. Roux

 

In the clinics 

·         Adequate space in the building·,       

·         Students are properly dressed, clean gowns,

·         Use of disposable plastic bags for spitting and use of dust-bins,

 

In the sterilisation rooms

·         Pre-disinfection liquid is adapted and utilized,

·         Bucket for pre-disinfection is adapted and utilized,

 

Theoretical knowledge about infection control 

·         Students are systematically wearing gloves and masks,      

·         Surfaces are rather generally clean,

·         Tidying up after the patient treatment,

·         Some actors clinicians are aware of cross infection control,

 

 

Analysis of stakeholders of the Faculty 

 

Material aspects 

·         Adequate space in the building,

·         Materials available in the clinics (chairs, instruments,…)  

 

Human aspects 

·         Human resources: numerous teachers,

·         Authority of the leaders,

·         Voluntarism, desire to improve the facultyFaculty,

·         Numerous foreign partners,

·         Even though the conditions are difficult, there is staff involvement.

 

 

 

Weak points

Analysis from G. Clapeau and D. Roux

 

In the clinics 

·         No systematic hand washing, no towels, few liquid soaps,

·         Contamination by the gloves: they are worn too early and students move around too much,

·         Multiple use of masks,

·         No sorting out of sharp, contaminated and non contaminated waste,

·         Dental chair and unit are not cleaned after each treatment,

·         Lack of established and displayed protocols,

·         No starting up of the units and flushing of the equipment,

 

In the sterilisation rooms

·         Rooms are too small,

·         Protocols are not establish and displayed,

·         No uniformity of the different sterilisation rooms,

·         Clean and dirty circuit crossing, no clear zones,

·         No total immersion of the instrumentation during pre-disinfection,

·         No treatment circuit for the instrumentation,

·         Conditioning before sterilisation is inexistentnon-existent,

·         No control on the quality of the autoclaves and dry heat sterilisers

 

Treatment of linen

·         No facility and protocol for the treatment of linen, gowns,…

 

Knowledge about infection control 

·         Knowledge is insufficient, lack of training of the nurses working in sterilisation rooms,

Analysis of the stakeholders of the Faculty 

 

 

Material and financial aspects 

·         Low budget for running costs,

·         Low wages for the teachers,

·         Lack of material in the clinics,

 

Human aspects 

·         Problems of motivation of the staff (bound to the wages),

·         Skills of the staff,

·         Communication problems between the personnel, 

 

4 . RECOMMENDATIONS

By  G. Clapeau and D. Roux

 

In the clinics 

·         Establishment and display of protocols,

·         Starting up the dental units with flushing (the morning and between every patient),

·         Wash hands before gloving and after gloves are removed,

·         Use towels for hand drying,

·         Avoid to recap the needles,

·         Improvement for sorting out the waste = separate sharp items, contaminated and non contaminated,

·         Cleaning of the surfaces, dental chair, units after every patient,

·         Anticipation of which materials and instruments will be required for a patient to the needs in material to decrease the movements and the chance of cross-infection

 

In the sterilisation rooms

·         We recommend a central sterilization area (see details in appendixAppendix),

·         Establishment and display of ·protocols,

·         Complete immersion of the instrumentation in pre-disinfection,

·         Zoning and circuits for the treatment cleaning, sterilisation and storage of instrumentationinstruments,

·         Conditioning before sterilisation,

·         Control on the quality of the autoclaves or dry heat sterilisers, and regulation of the sterilising times

·         Verification of sterilisation by for example autoclave tape

 

 

 

 

For the treatment of linen 

·         Creation of a linen room (for tissue masks, towels, gowns,…)

 

For the theoretical knowledge improvement 

·         The infection control course should be integrated in with the curriculum,

·         Training of the nurses working in sterilisation rooms,

·         Provide scholarships for staff responsible of infection control,

 

For the application of the recommendations, assessment and follow-up:   

·         To establish a project document with planning, and budget,

·         To designate one or two people responsible for the project,

·         Setup working groups for the establishment of protocols,

·         Regular internal audit,

·         Purchase material on the local market if possible,

·         Improve maintenance of material,

·         Another evaluation should be done in one year with the same grid with the objective to reach 70% of the optimal level, 

 

Some simulations:

 (+ means improvement)

+ systematic hand washing = 58,.9 %+

+ Starting up the dental units with draining the morning and between every patient: 63,.4%

+ sorting sharp and contaminated waste : 70,.3%

+ cleaning dental untis units and aspiration after treatment: 74,.4% 

 

 

 

 

 

By stakeholders of the Faculty 

 

In the clinics 

·         The faculty Faculty can buy liquid soap to improve the hand washing,

·         To have a sufficient and permanent water for hand washing,

·         For the treatment of waste: incineration     

·         Use of the rubber dam,

 

 

 

 

 

In the sterilisation rooms 

·         Setup a central sterilization with the possibility to add an adjoining room to the sterilization of restorative clinic

·         Purchase big autoclave and big boxes

·         Sets of instruments should be prepared for particular procedures eg examination set, Material should be conditioned by kits of instruments (ex probes mirrors - precelles, material for 1 amalgamamalgam set, scaling set, material for 1 scaling etc..).

It should be individu: amalg, scaling etc.. 

·          

 

 

For the treatment of linen 

·         Creation of a linen room (for tissue masks, towels, gowns,…) and training of a nurse,

·         The faculty Faculty will buy a washing machine (300 $US)  

·         To have a numerous cotton masks available 

 

 

 

 

 

For the application of the recommendations, assessment and follow-up:  

·         Designation of 4 responsible persons to follow infection control in the clinics (1 by in each department),

·         Choose motivated teacher  to participate tocoordinate the project,

·         New evaluation by G. Clapeau and D. Roux in one year,

·         To reach a level of 90%  for the next evaluation (seriously?). 


 

 

 

 

 

APPENDICESX

APPENDIX 1

 

EVALUATION OF THE CROSS INFECTION PROCEDURES AT THE

FACULTY OF ODONTOSTOMATOLOGY OF IN PHNOM PENH 

Departments visited: Pediatric dentistryDentistry, Restorative, Surgery and Prosthetics.

Evaluators: Guillemette Clapeau and Dominique Roux 

Date: 22nd  January 2002

 

 

 

 

 

 

 

 

 

 

 

 

 

ITEMS EVALUATED 

Good

Med

uns Uns

noNo

Note

comments

 

 3

2 

 1

0

 

 

CLEANLINESS OF THE CLINICS 

 

 

 

 

 

 

Cleanliness of the walls

3x

x

 

 

11

 

Cleanliness of soils   (what are soils?)

x

x

2x

 

7

 

Cleanliness of straw mattresses 

4x

 

 

 

12

 

Cleanliness of the dental chairs

4x

 

 

 

12

 

Cleanliness of shelves of dental units

4x

 

 

 

12

 

Cleanliness of the spit-bowl

3x

x

 

 

11

Plastic bag for dust-bin=spit-bowl

Cleanliness of suction unit

4x

 

 

 

12

when it exists

Presence of a dust-bin

4x

 

 

 

12

plastic bag in spit-bowl

PROTOCOLS FOR THE BEGINNING OF THE DAY

 

 

 

 

 

 

Jewelleries - watch taken off

2x

 

 

2x

6

 

Hand washing (with liquid soap)

 

 

 

4x

0

 

Wearing gown

4x

 

 

 

12

 

Control of the unit, starting up the unit

 

 

 

 4x

0

 

Flush of the dental units, handpieces, air/water syringes

 

 

 

4x

0

 

PROTOCOLS BEFORE TREATMENT

 

 

 

 

 

 

Withdrawal of material in the sterilization 

 

 

4x

 

4

Repeated many times

Installation of the patient 

 

x

 

 

 

 

Wearing  mask

 

4x

 

 

8

Often on the chin – multiple uses

Hand washing (liquid soap)

 

x

 

3x

2

Friction with alcohol

Wearing gloves

 

4x

 

 

8

often put too early 

DURING TREATMENT

 

 

 

 

 

 

Use one needle by patient 

2x

 

 

 

 

non observed in the 2 other

Use of one anaesthetic cartridge by patient

2x

 

 

 

 

non observed in the 2 other

Respect of the asepsis protocol

 

4x

 

 

8

Not logical
PROTOCOL AFTER TREATMENT

 

 

 

 

 

 

Gloves and masks removed and thrown to the dust-bin 

 

4x

 

 

8

Gloves are not removed immediately after care

Tidying up

3x

x

 

 

11

 

Sorting of the waste

 

 

 

4x

0

 

Return of the instrumentation to the sterilisation room

4x

 

 

 

12

 

Handpieces cleaning 

 

 

x

 

 

In sterilisation with humid tissue (water?) 

Cleaning of surfaces (chair, unit,…)

 

 

 

4x

0

 

Cleaning and rinsing of suction unit

 

 

 

4x

0

 

Hand washing (liquid soap)

 

 

 

4x

0

2 times with powder

 

 

 

 

 

 

 

STERILIZATION ROOMS

 

 

 

 

 

 

Cleanliness of the walls

x

2x

x

 

8

 

Cleanliness of soils  

x

3x

 

 

9

 

Plane surface cleanliness 

2x

2x

 

 

10

 

Cleanliness of storage cabinets

 

 

4x

 

4

 

Solution for pre-disinfection

4x

 

 

 

12

careful sometimes aldehyds

Use of gloves

4x

 

 

 

12

 

Dilution of the pre-disinfectant solution

 

4x

 

 

8

with difficulty controllable

Bucket  for  pre-disinfectant

4x

 

 

 

12

 

Immersion of the instruments

 

 

4x

 

4

still incomplete

Time of immersion

4x

 

 

 

12

 

Washing - mechanical action

4x

 

 

 

12

avoid spontex

Rinsing

x

 

 

 

 

3 seen not

Disinfecting solution (thermo - sensitive material)

 

 

 

 

 

not used

Sterilisers

 

 

 

 

 

disparate: 2 autoclaves, and 2 dry heat

Drying pre disinfected material (with tissue)

 

 

 

4x

0

air

Conditioning of pre disinfected material

 

 

 

4x

0

 

Time and temperature for sterilisation

 

x 

 

3x

0

 3 not defined

Display of the protocols

 

 

 

4x

0 

 

 

 

 

 

 

 

 

Room cleaning

 

 

 

 

 

Not seen

Zoning

 

 

 

4x

0

 

Treatment of waste 

 

 

 

 

 

 

Contaminated waste

 

 

 

4x

0

 

Non contaminated waste

 

 

 

4x

0

 

Sharp – cutting waste 

 

x

 

3x

2

 

Wastes of amalgam 

 

 

 

4x

0

 

Dust-bins 

 

 

 

 

 

Not seen

Treatment of linen

 

 

 

 

 

 

Operative fields

 

 

 

 

 

Not seen

Towel 

 

 

 

 

 

Not seen

Linen for sterilization room

 

 

 

 

 

Not seen

Linen for unit and dental chair cleaning

 

 

 

 

 

Not seen

Gowns

 

 

 

 

 

At home

 

The percentage of 52% (51,.7) was calculated by the following way:

 

To every appreciation was affected a noteFor every item above, scores were given: Good = 3, Medium = 2, Insufficient = 1 and non madeNot observed  = 0. The notes scores of the 4 departments were added together by item.

 

A total of 44 items were observed in a sufficient way to be taken in account in the notation calculation (the non not or insufficiently observed items were not taken in account).

For every item the maximal maximum score note is was 12 (4x3), and the sum (S) of the total possible points for all items is was 528.

 

The sum of the notes scores assigned to every item is 273.

 

The final result gives a percentage of 51.,7% of the optimal level. (273x100/528).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPENDIX 2 

 

 

RECOMMENDATIONS FOR A CENTRAL STERILISATION AREA AT

THE FACULTY OF ODONTOSTOMATOLOGY OF IN PHNOM PENH 

 

 

The faculty Faculty of odontostomatology Odontostomatology is willing to create a central sterilization area and a linen room. This project should be organised with the involvement of dentists from every department.

 

 

1.   SETTING UP OF THE PROJECT 

 

The dean Dean must organise a solemn meeting to present the project. With AOI, they should decide the list of the guests, including: the professors, the students, the other staff (nurses working sterilization and cleaners).

Two groups should be set-up :

-     a piloting committee

-     working groups groups to achieving help collect information and implement the different studiesparts of the project.

These people must be voluntary and motivated.

 

 

1.1.The piloting committee

 

It is should be constituted of people involved in the project. It should not include more than 6 people, in order to facilitate the work.

Example:

-     Suorn Phany (the deanDean)

-     AOI

-     Hong Someth (teacher in surgery and cross-infection con troll)

 

This committee’s job is is assigned to start andorganise and to follow monitor the collection of information and necessary studies activities for the setting up of a central sterilization area, to validate the reports of every working group, and to take make the decisions.

 

1.2.The working groups 

 

They must be composed of the different people personnel related to the each part of the asked studiesproject. One of the members of the piloting committee must be systematically present in each of the working groups because he should conduct the meetingsand act as chairperson. He This person cannot be the same for each of the groups.

 

Every group has a specific survey tasks to achieve.

 

1.3.The subgroups 

 

They are often necessary to achieve every survey with the concerned peoplethe desired outcomes.

 

 

Minutes should be written after every meeting.

 

 

2.      SURVEY OF THE EXISTING  SITUATION

 

2.1.Survey of the circuits 

 

-          draw the architecture of the faculty Faculty in several virgin original copies,

-          drawn clean and dirty circuits on one the plans. (Usually the clean is signalled in green and the dirty in red).

 

2.2. Survey of the clinic activity 

 

The activity is calculated: 

-     for one year (it may exist)

-     per month if it is not monthly regular

-     per week if there is strong variation by month

-     per day if there are peak days.

 

2.2.Survey of volume 

 

This survey is decomposed like the following:

·         inventory of the whole materialequipment:

-     devices

-     furniture

-     tables

-     dental chairs

-     brooms

-     buckets

-     bowls

-     containers for decontamination….

 

·         inventory of all the instrumentsation

·         inventory of the staff (for a possible different distribution)

 

This inventory is made by for each service and then gathered in one onlycombined.

 

 

2.3.            Survey of the expenses

 

This must should be based on one year, and include all purchases, investments, salaries, donations…

 

 

 

 

 

 

 

 

 

 

3.      SURVEY FOR THE PROJECT 

 

3.1.Elaboration of the plans 

 

Site of the future central sterilization

Site of the future linen room

 

3.2.Inventory of the necessary material 

 

Material Equipment and materials already owned

Material Equipment and materials to buy

 

3.3.Survey of cost 

 

3.4.Plan of the sterilization and linen room

 

4.      ELABORATION OF THE PROTOCOLS  

 

This must be done by working groups while approaching the different

paragraphs presented in the audit.

 

5.      CONSTRUCTION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPENDIX 3: PLANNING  

 

 

DATES

ACTIVITIES 

PARTICIPANTS

Arrived Sunday

20th January  2002

Discussions

 

Monday 21   

Morning :Visit dental nurse training, Kompong Cham

 

Afternoon : Visit to the faculty Faculty of odonstomatology Odonstomatology of Phnom Penh : Discussions on the method and the programme. Short visit of the services.

 

Redaction of the grids for evaluation in the evening.

 

ICC

F.Courtel

D. Roux

G. Clapeau

 

Dr Suorn Phany (Dean)

Tuesday 22  

Morning: 

Evaluation of the infection control procedures at the facultyFaculty.

 

Afternoon: 

Synthesis and writing report.

F.Courtel

D. Roux

G. Clapeau

Dr Hem Chin (Vice-dean)

Wednesday 23 

Morning: 

Restitution and discussion with stakeholders. Presentation of the analyses. 

 

Afternoon   :

Synthesis and writing report. 

 

 

 

Deans,

Teachers, head of departments,

Nurses from sterilization, 

 

F.Courtel

D. Roux

G. Clapeau

Thursday 24 

Morning   :

Lecture about infection control. G. Clapeau

 

Afternoon: 

Visit to ASPECA.

Meeting with EUROP CONTINENTS and MEDICOM, suppliers of medical material. Finalisation of the report. 

Students 4,5 and 6th year.

Teachers and private dentists. 

Friday 25

Morning: 

Recall of the analysis by G. Clapeau, D. Roux and by stakeholders.

Establishing objectives by both sides.

Writing recommendations 

 

Afternoon:  Visit of the dental service of the Calmette hospital.

Deans, head of departments, 

 

F.Courtel

D. Roux

G. Clapeau

Saturday 26   

Return to France for D. Roux and G. Clapeau