Comprehensive Dental Office Infection Control Program

1. Module 14 Infection Control and Related Health and Safety in the Dental Office Part 1

2. Infection Control and Related Health and Safety Kathy Eklund, RDH, MHP The Forsyth Institute Boston, Massachusetts

3. Objectives of an Infection Control Program • Reduce the available number of microorganisms • Interrupt the spread, break the cycle of cross-contamination • Treat all patients/clients and clinicians as if infected • Protect from exposure, infection and disease

4. Client assessment Immunizations for HCW and Patients Exposure incident prevention and management Universal Precautions/ Standard Precautions Personal Protective Equipment Instrument Processing and Sterility Assurance of Patient Care Items Environmental Management of Clinical Contact Surfaces Housekeeping practices environmental asepsis waste Hazard communication Elements of an Effective Infection Control Program

5. Universal Precautions/ Standard Precautions • Treat every one as if infected with a pathogenic microorganism • Handle every contaminated item as if carrying a bloodborne infectious agent

6. System of infection control and related health and safety that is procedure specific, not based upon the known or unknown sero-status of client

7. Standard Precautions • Standard Precautions synthesize the major features of Universal (Blood and Body Fluid) Precautions (designed to reduce the risk of transmission of blood-borne pathogens) and Body Substance Isolation (designed to reduce the risk of transmission of pathogens from moist body substances) and applies them to all patients receiving care regardless of their diagnosis or presumed infection status. • Standard Precautions apply to (1) blood, (2) all body fluids, secretions, and excretions except sweat, regardless of whether they contain visible blood, (3) non-intact skin, and (4) mucous membranes. • Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals [ Guideline for isolation precautions in hospitals Part II, Recommendations for isolation precautions in hospitals]

8. Spaulding’s Classification Items and Chemicals Summary • Critical - Penetrate Tissue • single use disposable, sterilize • Semi-critical - touch nonintact tissue/mucous membranes • sterilize preferred; high level disinfection • Non-critical – touch intact tissue • Clean and low-level disinfection

9. Spaulding’s Classification (con’t.) • Non-Critical Clinical Contact Surfaces • Clean and intermediate level disinfection (use a hospital level/tuberculocidal agent) or • Use Surface and Equipment Barriers/Covers

10. Topics for This Talk • Instrument Processing and Sterility Assurance • Dental Handpieces and Aseptic Management • Dental Unit Water Quality

11. Instrument Reprocessing and Sterility Assurance

12. Goals • Sterility assurance for patient protection • “all reusable instruments and handpieces are sterilized (rather than just disinfected) between use on patients”. Chris Miller, Ph.D • Achieve maximum efficiency in instrument processing • Provide safety for the worker and the patient throughout all aspects of the process

13. Objectives • To have clear written policies • To use safe procedures • To select cost effective products and equipment • To create a sound operational flow for processing instruments • To evaluate safety, efficiency and effectiveness

14. Instrument Reprocessing • Chairside Handling and Management • Transport of Contaminated Instruments • Holding (presoaking) ????? • Instrument Cleaning • Instrument Packaging • Sterilization • Sterilization Monitoring • Storage of Packaged Sterile Instruments

15. Chairside Handling and Management • Using Instruments/Sharps Safely • Debridement - pre-cleaning • Passing • Sharpening • Containment of Instruments for Transport

16. Principle • Prevent Sharps injuries by using safe products, devices, and practices.

17. Types of Occupational Exposures to Bloodborne Pathogens • Percutaneous injury (PI) • Mucous membrane • Non-intact skin • Human bites

18. Prevention Strategies Engineering controls Personal protective equipment Work practice controls

19. Prevent Percutaneous Injuries • Use medical devices with engineered safety features designed to prevent injuries and/or by using safer techniques • Self-sheathing needles/needles with engineered safety features • passive vs active • Do not recap needles by hand • Do not disengage needles from a reusable syringe by hand • Use disposable needle syringe systems • Dispose of needles in appropriate sharps disposal containers

20. Prevent Percutaneous Injuries (continued) • Avoid hand contact with sharps • Do not debride instruments on gauze by hand . Use a single-hand technique, such as: • Cotton rolls taped to the instrument tray • Use a commercial safe wipe device

21. Prevent Mucous Membrane and Skin Exposures • Avoid exposure to eyes, nose, mouth, or skin by using appropriate barriers • Gloves • Eye and face protection • Clinical attire

22. Safe Instrument Handling for Processing

23. Instrument Transport • Containment • The Container • PPE • Labeling

24. Contaminated Instruments • Wash and dry hands • Wear appropriate PPE, including puncture resistant gloves • Transport contaminated instruments in an appropriate container directly to the receiving area of the sterilization area • Do not rinse, scrub, or unnecessarily handle contaminated instruments in the operatory

25. Contaminated Instruments • Receive contaminated instruments in the “dirty” only area • Isolate contaminated items to be cleaned to prevent unnecessary exposures • Keep the area separated by “dirty”, “clean”, and “sterile” designations • terms/designation terminology may vary

26. Principle • Clean and package instruments and items as soon after use to eliminate the need for the presoak step.

27. Holding (presoaking) • Indications for Presoaking • Methods • Presoak Solution • Holding Container • Management • Hazard Communication/Labeling

28. Holding/Presoaking • Purpose is to keep bio-burden/debris moist until proper cleaning can occur. • Presoak solutions need only be water that contains a surfactant that is low in corrosion. • Disinfectants are not needed or indicated for presoaking

29. Instrument Cleaning • Methods • Ultrasonic Cleaning • Thermal Disinfection • Instrument Washers • Manual Hand Scrubbing • PPE • Injury Prevention Strategies

30. Principle • Always clean before sterilization

31. Methods: Ultrasonic Cleaning • Current Technology • Management • Space Commitment • Infection Control and Safety Considerations • Hazard Communication Labeling • Follow Manufacturers Directions for Use

32. Methods: Thermal Disinfection/Instrument Washers • Current Technology • Management • Space Commitment • Infection Control and Safety Considerations • Hazard Communication Labeling • Follow Manufacturers Directions for Use

33. Methods: Handscrubbing • Infection Control and Safety Considerations • PPE • Injury Prevention

34. Instrument Packaging • Principle • Materials/products • Process • Labeling

35. Principle • Items should be packaged for sterilization and storage. Items should remain packaged to the point of use.

36. Selection of Packaging Materials • Criteria • compatibility with sterilization method • safety considerations • labeling requirements • appropriate for the items to be processed • storage requirements • FDA cleared for market

37. Compatibility with Sterilization Process • Steam Autoclave • Gravity Displacement (121°C/250°F – 132°C/ 273°F for 30 minutes) • Prevacuum Sterilizer (132°C 270 °F for 4 minutes) • Pouches/Tubing (paper, paper/plastic, nylon, polypropylene) • CSR Wrap (muslin, paper, polypropylene)

38. Compatibility with Sterilization Process • Dry Heat (Convection @320°F): • Pouches/Tubing (paper, paper/plastic, nylon) • Closed containers, paper CSR wrap • Dry Heat (Rapid Heat Transfer @375°F): • Pouches (heavy gauge nylon)

39. Compatibility with Sterilization Process • Unsaturated Chemical Vapor (273°F): • Pouches/Tubing (paper, paper/plastic) • CSR Wrap (paper) Caution: Maximum load size = 3.3 lbs. No other packaging materials can be used!

40. Legal Reminder… • Packaging materials are considered CLASS II devices and must be cleared for market by the FDA or have pre-market clearance!

41. Packaging Process • Pouches/Tubing – use an instrument rack if available to aid sterilant contact and drying. Instruments in pouches lying flat should be in a single layer. Tape or heat seal per the Mfg.’s recommendation. • CSR wrap - should be double layered when packaging cassettes or instrument trays.

42. Labeling/Identification • Contents/ Type of set-up • Depend upon visibility through packaging material • Date, Sterililizer and Cycle number • Owner/operatory for items • Other ( e.g. BI monitoring cycle)

43. Sterilization • Defined • Principle • Methods • Selection Criteria • Infection Control and Safety Considerations • Space Considerations

44. Sterilization Defined • The process of killing all microbial life forms, including bacterial endospores

45. Principle • “Don’t dunk it, cook it”. Walter Bond, CDC • Never disinfect when you can sterilize.

46. Methods • Saturated Steam • Saturated Chemical Vapor • Dry Heat - Rapid Heat Transfer • Dry Heat - Convection • EO Gas • Chemical Immersion • Other

47. Legal Reminder… • Sterilizers are considered CLASS II devices and must be cleared for market by the FDA or have pre-market clearance!

48. Selection Criteria • Site specific selection criteria • May need more than one method of sterilization • Size of practice • Instrument inventory • Types of instruments and materials to be sterilized • Space considerations

49. Sterilization Infection Control and Safety • PPE • Hazard Communication Labeling • Handling of Sterile Packaged Items

50. Follow Directions • Use • Item and Packaging Compatibility • Cycle Parameters • Unwrapped vs. wrapped • CI and BI Monitoring Requirements • Routine Maintenance • Warranty Requirements