The HTM 01-05 regulations are intended to minimise the risk of cross-infection and contamination in dental practices. Dental nurses are often responsible for cleaning, sterilising and storing instruments, so need to understand them

Since the publication of HTM 01-05: Decontamination in Primary Care Dental Practices in 2008 (Department of Health (DH), 2013), we have seen a huge shift in attitude among dental professionals regarding decontamination and cross-infection.

HTM 01-05 was drawn up to maximise infection prevention and control. It gives practice teams, including service engineers and surgery designers, comprehensive guidance on instrument decontamination cycles and on providing the optimal environment for safe practice. The version published in 2013 updated some parts of 2009 document, especially around the storage or sterilisation of instruments.

HTM 01-05 encourages dental practices to reach ‘best practice’ standards. However, it will be difficult for all practices to do so; for example, many are in premises that were not built for clinical purposes, such as converted homes or offices and listed buildings, and their size or structure restricts how they can be adapted.

Essential practice

In the meantime, primary care dental practices must meet minimum standards, formally known as ‘essential quality requirements’ (DH, 2013).

These includes:

• ? A dirty to clean zone workflow

• ? Uncluttered work surfaces

• ? Storing reprocessed instruments in such a way to prevent microbiological recolonisation; this should be managed by a careful stock control process, including labelling and record keeping

• ? Practices should audit their decontamination processes quarterly using an audit tool

• ? Practices should have a detailed plan of action and timescale on achieving best practice.

Before sterilisation, instruments must be free of contaminants and should be inspected under an illuminating magnifying device after they have been cleaned (DH, 1999). Instruments should have a validated decontamination cycle including cleaning/washing (this will include written protocols for manual cleaning) and sterilisation in a validated steam steriliser; at the end of the reprocessing cycle, instruments should be sterile.

Reaching essential practice can pose a financial strain on practices. It will cost smaller practices, which often have one or two surgeries, proportionally more per surgery than multi-surgery practices to comply. In its response to consultation on the Health and Social Care Act 2008 Code of Practice (DH, 2010), indemnity provider Dental Protection said that the combined effects of the code and the HTM 01-05 (DH, 2013) may cause a small minority of small practices to close.

Dental Protection (2010) also said that not all practices would have the physical space to comply with HTM 01-05, and some would have to use space that could be used for a dental surgery for decontamination management purposes.

The daily running costs of meeting the required standards can be divided into two categories;

• ? Staffing

• ? Equipment.

Staffing costs

Training

With the responsibility for reprocessing instruments in dental practices falling largely on the shoulders of dental nurses, it is vital that these members of the practice team are fully conversant with any amendments to HTM 01-05. Although the changes made in March 2013 are relatively minor, it is nevertheless vital that nurses are aware of them.

Infection control/decontamination lead

This nominated member of staff will require training and need time to familiarise themselves with the role. This person can be any clinical staff member but is usually a dental nurse; they are required to be vaccinated against hepatitis B (DH, 2010).

The role could involve producing an annual report and writing polices as well as undertaking quarterly audits and feeding back the results to the registered dental care provider. The rest of the dental team could also benefit from this information.

Competent person (decontamination)

This person is responsible the for servicing, maintenance and testing of decontamination equipment. This can be someone who is already employed by the practice or an external engineer.

User/operator

This person is responsible for the daily operation of decontamination equipment and has to ensure that all other operators have been trained to use it. This is usually a dental nurse; practices may employ a dedicated sterilisation nurse for this role.

Shared responsibility

In larger practices, duties may be shared between team members, which will increase accountability and lead to a more unified standard of care. Sharing the workload also means that lead decontamination nurses will not need to be taken away from their clinical duties as often.

Equipment

I understand that practices that were working below standards before the regulations were introduced or whose planning for and understanding of the guidance was poor had to make a substantial initial outlay on purchasing equipment.

Record-keeping and audit

Audit tools need to be completed quarterly. Additional costs will be incurred in carrying out the changes required as a result of the audit.

Best practice

This involves:

• ? The use of an automated washer-disinfector

• ? Separate decontamination suite, with a dirty and a clean zone in two separate rooms with each having an individual air supply and extractor

• ? Suitable storage of instruments (DH, 2013a).

Dental Protection (2010) has said that achieving best practice may cost approximately £20 000 per dentist. In addition to this, some practices may not be able to adapt their building to meet this standard.

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Conclusion

Infection control will remain a priority not only for the government but also for the dental profession. It is fundamental that good infection prevention practice is consistent and proportionately applied in all sectors of care.

HTM 01-05 sets out information on the validation and verification of decontamination equipment and details the daily, weekly, quarterly and yearly testing protocols that must be required.

The DH must recognise that the costs of implementation and adoption these regulations are likely to be considerable. Some small practices that do not have the space, labour or financial capacity to adhere to the guidelines could be converted into central sterilisation dental units.

Since HTM 01-05 was published in 2009, knowledge of infection control has advanced, technology has evolved and research has uncovered more data on cross-infection control and decontamination.

It is encouraging that the updated HTM 01-05 document is evidence of this, while continuing to meet its aim to ‘progressively raise the quality of decontamination work in primary care dental services by covering the decontamination of reusable instruments within dental facilities’.

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Key Points

• ? Good infection prevention and control practice should be consistent and applied proportionately in all areas of care.

• ? Infection control and prevention has become a higher priority for dental practices since the publication of HTM 01-05: Decontamination in Primary Care Dental Practices regulations

• ? HTM 01-05 gives practice teams comprehensive guidance to provide the optimal environment for safe practice

• ? Dental nurses often have the primary responsibility for cleaning and sterilising instruments, so need to be fully aware of the regulations.

Author: MA Healthcare