OSHA and Infection Control Compliance Post-Pandemic

You're listening to the Phil Klein Dental Podcast We are all very grateful that the COVID pandemic is over, and it has been for almost two years now. But what does that mean for dental offices regarding infection control compliance? Do we just go back to what we were doing before? Do we use the same masks, gloves, and PPE and follow the same pre-pandemic infection control protocol? To answer some of these questions is our guest, Dr. Karson Carpenter. Dr. Carpenter is a practicing dentist who serves as president of Compliance Training Partners. He is an OSHA-approved trainer who has, for over 25 years, designed educational programs to bring dental facilities into compliance with the governmental regulations that affect them in the areas of OSHA, HIPAA, and infection control. Dr. Carpenter, it's a pleasure to have you on the show. Phil, it's great to be back. Thanks for the invitation. So the pandemic is officially over. It's been over for a while. There's still signs of COVID running around, as we all know. And as dental professionals, we have to be wary of that. But generally speaking, how have things changed post-pandemic in the area of infection control? Well, you know, I think what's really occurred is there's just a general awareness by doctors, by staff. of infection control at a level they never had before. I mean, let's face it. We always had influenza. We always had RSV. We always had the flu to contend with. Now people are being a bit more careful. They're screening patients better. Staff is staying home when they're sick. So, you know, I would like to say some good has come out of the COVID pandemic. Are you seeing what was projected at this time, that trio of flu, RSV, and COVID? Well, you know, I monitor CDC numbers quite closely. And so far, things seem to look pretty good. We're so much better than last year. At this point in the game, things look good. Also, it's really encouraging to see that it seems that we got the flu vaccine right. It's very effective this year. So you're an educator, Dr. Carpenter. You have a training company, compliance training partners. You've been around a long time. Do you honestly feel dental offices overall are a safe place to work? And are they just as safe for patients as ever before? You know, I really feel it's a safe environment. It's a safe place to work. And that's something I talk about when I lecture on a regular basis. I don't want staff members to be scared to practice dentistry. Do you remember during COVID when we saw in the front of Newsweek or U.S. News and World Report, world's most dangerous occupation, dentistry? Well, you know what? That just wasn't true. We were. Great PPE. We wear masks. We always have, even pre-pandemic. Gloves. We screen for respiratory disease. Do you know there wasn't a single cluster of COVID coming out of a dental office? I feel a dental office is an extremely safe place to work, and I tell dental staff that all the time. So if you were to look at all the different components of infection control within a practice, and that includes surface disinfection, PPE, wearing the right masks and gloves. proper and regular staff training, waterline contamination, aerosols. There's so many things, instrument sterilization, autoclaves, and it goes on and on. Is there one particular factor that concerns you the most as far as maintaining infection control in the practice? Well, you know, I would have to say if I could only pick one as being the most important, and they're all important in my mind, but to me, what's most important is training because everything comes from training. For example, Take a look at our sponsor tonight, Cranberry. The products that they make, for example, I'm a real fan of the 360 mask. It's an ASTM rated mask. It protects us. It protects the patients. But people don't use products like that unless they're trained. In fact, unless people are trained, they don't know what ASTM means. In fact, they may not even be using a true surgical mask. But to me, training. is the beginning of a safe office. And to me, if you're going to do that, you've got to appoint somebody. Make sure you're appointing somebody, a trusted clinical person, a well-organized hygienist, a well-organized assistant, and give them that responsibility to make sure we stay in compliance. And that's someone we typically call the infection control coordinator, someone who's working in the practice, already has responsibilities, like you mentioned, could be a hygienist or an assistant. but that person is held accountable to maintaining the protocol, documentation, the annual training, and so forth. And I think this is a really important thing to have in the practice. So you have someone who really enjoys this and takes the responsibility to follow CDC guidelines and maintain office compliance. You do agree that the designated infection control coordinator is the one really responsible to maintain the training in the office, schedule that training at least once a year, and so forth? They do. They do. Once that person is appointed, They have two major areas of responsibility. One is to make sure that everybody in the office is trained once a year. Even if they've been trained, annual infection control training is a requirement. Their other big requirement is, of course, making sure that new person is trained as part of the onboarding experience. And the third major function that they have is making sure they have written programs available that employees know where they're at and that they're up to date. So your company focuses on getting dental practices up to speed on infection control protocols so that they're compliant. Based on what you're seeing now, what liability concerns do you have for dental practice owners? I'm really glad you mentioned that because let's face it, we all know that infection control to protect staff, to protect patients, ethically, of course, is the right thing to do. But you hit on liability. And that's something I talk about all the time. If you don't have a quality, infection control program that follows CDC guidelines to protect your patients, you have a chance of ending up in court. You have a chance of losing your license. It's just not worth it. You need to do it to protect your business. In the same way, OSHA protects our employees. You need to be in compliance to protect the health of your business. So let's talk about the scenario where we have a... practice that's looking to hire more people. They want to grow their practice, add more operatories. So they're really focusing on so many different things. They're expanding their practice. What is your recommendation for that dental practice owner that's going through this with so many other things on their mind where they don't lose sight of how important infection control protocol is? Because the last thing they want to have is a setback where they have a disgruntled employee. Or for whatever reason, they're reported to the state board. They're reported to CDC or OSHA for a violation. Then there's inspections that follow. All of a sudden, they're looking at all sorts of headaches and it's kind of a nightmare. So to avoid that, what is your recommendation, especially to those dental practice owners that are growing quickly? Number one, appointing somebody to be in charge. Number two, just like when you take off in an airplane, you've got a checklist. Quite honestly, I would go to ComplianceTrainingPartners.com and download the detailed OSHA audit checklist, the detailed infection control audit checklist, and make sure that you do that at least once a year. Most things in your office are going to be checked. Yes, you're in compliance. Those that are no, you need to go in the left-hand margin and write down the date that you abated. If you don't have a flight plan, you're never going to get to where you're going. That's where I would start. So all dental practices, like every other business, is trying to save money wherever they can, especially in the dental office where the overhead can get quite high. There's equipment that has to be paid off. There's materials. There's HR. There's insurance. rent, and on and on and on. And especially if you rely on insurance for compensation, your profit margins are not going to be super, super high. So you can't blame an office for pricing out PPE. What is your feeling about that as far as safety and infection control? When you stop and think about it. The cost of PPE is not a lot. As a percentage of our practice budget, it's not a lot. And it doesn't cost that much more to buy a quality product. I would really try to dissuade people from buying inexpensive, super low-cost products, for example, on the web. When you're buying a quality product, again, I'll look to our sponsor tonight, Cranberry, when you're looking at a quality product purchased from a quality distributor on the mask end. You've got a mask that's been approved by ASTM International as a surgical grade mask. When it comes to gloves, you have gloves that fit properly, gloves that will not tear. Gloves, in fact, I'm a real fan also of this new bio nitrile glove that Cranberry has. What I like about it, being somewhat green myself, what a great thing that this nitrile glove will actually break down. completely in a landfill in about a year and a half. So does it cost you much more to buy a product like that? Not at all. So shop for quality products from a quality distributor. I think you'll be glad you did. And I think you'll provide more protection and comfort to your staff and to your patients. So based on your business, as we mentioned before, your goal is to get dental offices compliant with CDC guidelines, et cetera, and make sure they maintain that compliance. Based on your experience, what trends are you seeing right now regarding inspections of the dental office by CDC or OSHA? The major trend that I see is the fact that we've got staff members today that are more aware. When it comes to OSHA, we always have to remember OSHA is not concerned about our patients. OSHA is only concerned about the dental team members. Dental team members are informed. Dental team members know that they can contact OSHA if they're not being provided with the proper PPE. They're not being provided with annual training if they don't have written programs. So the trends I see in inspections are really more anonymous calls from dental employees triggering inspections. So tell us what you would do as a dental practice owner if you were... somewhat surprised with an inspection or you were told, you know, we're going to be coming by tomorrow morning and, you know, it's four o'clock in the afternoon the day before. So there's not much you can do at that point. Some of your staff has already left for the day. So they're coming in and they're kind of seeing things the way they really are. Not much time for preparation. How would you best handle that inspector? You know, that is a tough one, Phil. That is a tough one. This is something you've got to be prepared for. It's almost impossible to really change much in a day. Worse yet, how does it look when that inspector comes in, they interview staff and they say, this is great. I see you've got labels up and a spill kit and a compliance manual filled out. How long have you had this? Are you familiar with this? Yeah, we just started on this yesterday and the day before. That's not going to fly well. I think if you're going to have them come in, you've got to show them what you have. You have to be honest with them. You have to be humble and say that you'll be willing to make the changes. But a better solution is your one phone call away from an inspection. Get ready now. Start now. Go through these audit checklists. You'll be surprised in about a month. how far along this path you'll be. And then you'll be sleeping nights. You won't have to worry. Your staff will respect the fact that you're trying to protect them. And they won't be the dental team that's going to call OSHA on you. So since the pandemic, how much has actually changed in the way we do things in seeing patients and treating patients and cleaning up after patients, disinfecting after patients, between patients? How much has that all changed since COVID? Or is it basically, are we right back to what we were doing before COVID? What's interesting is we have found now through experience that in fact, we were getting some very good protection from our surgical mask, our level two and level three masks. That of course, now we don't wear N95 respirators. We don't need to. I think that what has happened is imagine these guidelines that we had. pre-COVID that maybe weren't followed as carefully as they should. What we're finding now is people are in fact following those guidelines. People are using the PPE that they should. They're also very glad, breathing a sigh of relief, knowing they don't have to wear a full face shield if they don't want to. They can wear safety glasses. They don't have to wear an N95 respirator. They can wear a quality surgical mask. So I think everybody's breathing a sigh of relief, realizing that it wasn't quite as bad as we thought, realizing that dentistry had a sterling record during COVID, and people are just more willing to be in compliance. I definitely see a higher level of compliance than I did before the pandemic. Do you recommend that we primarily use ASTM-3 surgical masks and kind of forego the lower level masks that we use in the past for exams and so forth? Well, I'll tell you, and first of all, I'll just mention Cranberry because I know the line well. You can purchase an ASTM 1, 2, or 3 mask. If it's a surgical mask, and we all need to be using surgical masks, it's rated either an ASTM 1, 2, or 3. If it's not rated that, it's probably a nuisance dust mask that you should be using to work on your car, not on a patient, which is, again, why I don't like to buy sheet masks online. An ASTM 1 will filter out. approximately 95 percent of bacterial containing aerosols three microns and larger whereas the level two and level three will filter out 98 of those same bacterial containing aerosols the difference is a level two and level three have fluid resistance with a level two having moderate fluid resistance a level three having high fluid resistance and you stop and think about the average day in a dental office we have aerosols from high speeds low speeds three-way syringes, ultrasonic scalers. So to me, in a dental office, a minimum is a level two, ideally a level three. And N95s, we don't need any more, pretty much, by the way. We really don't. We really don't. Yeah. And, you know, Phil, I know you haven't practiced in a long time. Let me tell you what a treat it was to practice in an N95 respirator. Very, very difficult. It really makes you appreciate. wearing a surgical mask again. If another pandemic emerged, though, would you recommend going back to N95s? I would until we know more about it. Let's face it. It's easy to look back now and say, well, you know, we never had to wear N95s. But you know something? We didn't have the data. It turns out that level two and level three masks did quite a good job. But if there was a new bug out there, we weren't quite sure what it was. Would I wear an N95? Absolutely. So as you mentioned earlier in this podcast, there's two distinct regulatory bodies that the dental office should be concerned about, and that's OSHA and CDC. And as you mentioned, OSHA is primarily focused on the employees, the staff members, and CDC is concerned about the spread of infection among all of us, employees and... So how does OSHA differ from CDC in their enforcement of their regulations? What I find is many practitioners have high respect and fear of OSHA, not so much CDC because CDC are called guidelines. OSHA is a federal regulation. But keep this in mind. OSHA, of course, is about employee safety, not only from infection, but from, you know, ventilation, noise, ionizing radiation, non-ionizing radiation, any aspect of safety in the office OSHA regulates. CDC, they're concerned only with the spread of infection. Two patients or two employees, they're concerned with both. But keep in mind that although there are guidelines, quote, CDC guidelines, they can be enforced by OSHA. I've seen them enforced many times by state dental boards, state public health departments. And of course, if you are unfortunate enough to end up in a court of law with a case regarding infection control, that's the standard to which they'll hold you is CDC guidelines. So as far as I'm concerned, CDC guidelines are law. In your experience, Dr. Carpenter, how prevalent is it for a dental practice owner to actually go in front of a judge or be? in a courtroom situation or in front of a state board where their license is at risk due to violations of CDC or OSHA guidelines? I will tell you that having done this for well over 30 years, I think having been involved in more OSHA infection control inspections in dental facilities than anybody in the U.S., that trend is definitely up. The only problem I have answering that question, I often will have a doctor ask me, well, how about in my county? What are the number of OSHA inspections? If there haven't been any in the last two years, I'm not worried about it. Here's the problem. You're one phone call away from an OSHA inspection. I've been involved in OSHA inspections in rural Alaska, where the inspector flew in on a bush plane. I've been involved in OSHA inspections on the U.S. Virgin Islands, which is, of course, the U.S. territory. OSHA has jurisdiction there. All because of a phone call. So to me, I wouldn't look at those statistics. I'd say, first of all, I got to do it because it's the right thing. But second of all, I'm one phone call away from a nightmare situation. And it's not that hard to do this. Look at a good quality checklist. Have a good quality written program. Do training once a year. And really, OSHA will cut you a lot of slack. I find OSHA to actually be quite fair and reasonable. if you've attempted to do the right thing. Where do you think the office is most vulnerable regarding the breakdown of infection control? In other words, what part of the infection control process is most commonly related to the spread of infection? Probably the greatest risk I see is surface disinfection, improper surface disinfection in the operatory. Simple things like not following standard precautions, not changing. gloves, if you can believe it, between patients, wearing the same mask multiple times. And probably the worst of all in terms of causing problems for a practice is when patients are worked on with instruments that are not sterile. I call that an infection control disaster. And we're involved in a lot of them. We're involved right now with one that happened just last week. Someone new was hired in the practice. They weren't properly trained. They saw the wrapped instruments. They look quite good, right? Wrapped instruments that have been through an instrument washer. They look beautiful, but they never got through the autoclave. They worked on, I think, 11 or 12 patients in that practice. And when they asked us for advice, we have to tell them the truth. You can't sweep this under the rug. Those 12 patients have to be informed. Your state public health department has to be informed. Phil, that is a nightmare for that business. What is typically the aftermath when something like that occurs? Well, I'll tell you what I've seen. First of all, as you can imagine, first they're a little scared, very scared. They've got to go in and have a rapid hepatitis B, C, and HIV test. They then need to be followed for up to six months. And now they're angry. Sometimes legal action begins at that point. And we all know the destructive powers to a dental practice of social media. Can you imagine the one practice I was involved in? Over 50 patients worked on with instruments that weren't sterile. How do you think those young mothers did on social media? That is something that can destroy your business. And I don't mean to scare people. I mean, remember, I'm telling you things like OSHA is really fair. They're really reasonable. But these guidelines that are set, we've got to follow them to protect our business. You know, I remember not too long ago, water lines. were a big topic on infection control and a potential danger to the patient. Because in many cases, dental practices did not focus on disinfecting their water lines. Where are we now with that? I would say we're at a better point. The biggest trend that I see is there's much more practitioner awareness of the need to maintain dental unit water lines. The bad news about dental unit water lines. They're very small, torturous tubes through our dental units. They have great, you know, smaller the tube, the greater the surface to volume ratio. They easily form biofilms, which in turn harbor and grow bacteria, which can be a major problem, which has resulted in closing of practices, major lawsuits. The good news is with proper maintenance. That doesn't have to happen. And when I say proper maintenance, I'm talking about periodic shocking. At Compliance Training Partners, we recommend shocking quarterly at a minimum. I'm a real fan of diluted bleach to do it. We recommend a full-time low-level disinfectant being run through the lines 24-7, when you treat the patients as well, something that's safe interorally. We also recommend drying out the systems on the weekend, purge them of water. And testing, testing. We've got to test our dental units quarterly. The EPA recommends it. OSAP recommends it. Every major dental unit manufacturer recommends it. Now, we've been in the testing business for many years. We see a dramatic increase in practitioners testing and, of course, recording their results once again to protect their business. How do you think it goes if Mrs. Smith got Legionella from somewhere else? but blames it on your dental unit water and you don't have testing data. So protect your business, test your water every quarter. And you have information on those checklists and some of those supplemental handouts on your site that will help dentists go the right route regarding testing. We do, we do. Just follow those guidelines and that's going to tell you where you're in compliance and where you're not. Now focus as a team on the areas you're not in compliance. Like anything else, it's when you do it, regularly and you have a plan and a strategy and you have a team that everybody knows what they're supposed to do, it becomes part of the mechanism of the office. The gears are turning and it's just another part of the practice that you have to focus on to maintain safety in the workplace. So let me ask you this. During COVID, you couldn't go a minute without hearing about aerosols when it came to dental practices. Dental hygienists were very concerned. You could imagine what kind of fear they had with the aerosol that was created from an ultrasonic scaler. So a lot of what happened was these offices implemented air filtration systems and they put them near the dental chair and it pulled the air in and these things were not inexpensive and they were difficult to come by during the pandemic. Where are we now with air filtration systems regarding all this? One thing to keep in mind is that those filtration systems were always a recommendation, not a requirement. I myself never used one, but my practice had semi-open design, good circulation, a very good filter on the HVAC system, windows that would open. I will tell you that had I practiced again on the 20th floor in Midtown Manhattan, small office, no opening windows, I might have considered one of those. So it's purely optional, but I would gauge your office. What type of circulation do you have? And what about some things that are less expensive, less cumbersome, like simply improving your heating and cooling system, maybe a better... and larger blower motor, a better filtration system. I think there's easier ways to do it than have these devices laying all over our hallways. When we talk about infection control protocol in a practice, it's very important, of course, to stop the chain of infection from spreading. But in addition to that, patient perception is very important. Because I know when I go into a dental office, I look around, I like to see the staff wash their hands, put on fresh gloves. I don't want to see a staff member touching their face with their gloves. These are all things that are very important to me personally. And I think the same applies to many other patients. How important is it for the staff, the team, the dental team to really portray to their patient population that they're very focused on keeping the office clean and safe for them regarding infection control? I think it starts at the top. I think that the whole team needs to know. how important this is to the doctor. I actually always have and suggest in everybody's employee policy manual that they put the words, failure to follow OSHA and infection control guidelines, rules, laws as taught may be grounds for dismissal. Everybody needs to know we're serious about this. In the training that we're talking about once a year, infection control slash OSHA training, I think we need to emphasize just what you said, Phil. We have an informed patient base. People read. People know about infectious disease. They get on the internet and read about it. People are watching us. And you're right. Touching countertops and then touching inside of their mouth, that's not acceptable. Touching your face with the glove that you're going to work on with that patient is not acceptable. People are watching. Staff needs to know that. And we always need to ask them the question. What would you like to see if you went into an office? And is that part of the training that you suggest that these offices get annually? I do. I do. I think it's very important. And in that sense, it's really a marketing tool. Today, patients will go to an office that they perceive as safer, even if it's more expensive. And that's why when I'll have doctors say, do I need to train my front desk staff on infection control? Does OSHA really cover them? I say they may be the most important. person in the office to train. They're the ones who receive that call from that new patient who says, is this a safe place to go? Do you follow OSHA and CDC guidelines? That staff member needs to be very sharp on this. Just as sharp is the hygienist who sees patients every hour. So as we wrap up this podcast, and we've covered quite a bit of questions here, what is the best way to get an office in compliance? Like how would an office start and say, You know, we've been doing things pretty carefully over the years. I think we're in good shape. We've never had an inspection. I keep my fingers crossed that we don't have an inspection. But in the event of an inspection, they need to be in compliance. It's not an opinion thing. There's a rigid protocol that says you're either in compliance or you're not as far as CDC guidelines. So how does one get in compliance? What's the best way to start? To me? Again, compliance, there's two major things. One is the training aspect. One is having the hard stuff, the equipment, the eye wash, the spill kit, the compliance manual. To me, here's how I would start. And don't feel bad if you know you're not in compliance, that you haven't paid attention to this. You can change starting tomorrow. Step one, appoint trusted clinical person in the office to be in charge. Step two, have them download our compliance audit checklist for ocean infection control. On with the end of that checklist, you're going to then see what things you're missing. Maybe it's a compliance manual. Maybe it's written policies. Maybe it's an eyewash. Maybe it's testing for your water. But start with a person who's held accountable and give them that flight plan. And I will tell you that you're going to be in really good shape in less than a month. Dr. Carpenter, it's been a great podcast. You've covered a lot of material. We really appreciate your time. To our audience, if you're looking to get more information on CDC and OSHA training and compliance and checklists, they're free. Go to ComplianceTrainingPartners.com. You'll be able to get these supplements that will help you with what you're doing as far as protocol and setting up your office to be compliant. Again, We look forward to having you on a future program soon, Dr. Carpenter. Thank you very much. You're welcome, Phil. Thanks again for having me. Always a pleasure. If you're enjoying this podcast, please leave a review or follow us on your favorite podcast platform. It's a great way to support our program and spread the word to others. Thanks so much for listening. See you in the next episode.