2 TOSHA believes the information in this presentation to be accurate and delivers this presentation as a community service. As such, it is an academic presentation which cannot apply to every specific fact or situation; nor is it a substitute for any provisions of 29 CFR Part 1910 and/or Part 1926 of the Occupational Safety and Health Standards as adopted by the Tennessee Department of Labor and Workforce Development or of the Occupational Safety and Health Rules of the Tennessee Department of Labor and Workforce Development.
4 Topics To Be Covered1) Bloodborne/Waterborne/Airborne Disease Transmission2) Barrier Precautions3) Needlestick Precautions4) Disinfection/Sterilization5) Infection Control6) Universal Precautions
5 9 Million Persons Work in Health-Care Professions 168,000 dentists,112,000 registered dental hygienists,218,000 dental assistants53,000 dental laboratory techniciansDental health-care personnel (DHCP) refers to all paid and unpaid personnel in the dental health-care setting who might be occupationally exposed to infectious materials, including body substances and contaminated supplies, equipment, environmental surfaces, water, or air.
6 Pathogenic Microorganisms Dental patients and DHCP can be exposed to pathogenic microorganisms including:HBV, HCV,herpes simplex virus types 1 and 2,HIV,Mycobacterium tuberculosis,staphylococci, streptococci, and other viruses and bacteria that colonize or infect the oral cavity and respiratory tract.
7 Organism Transmission 1) Direct contact with blood, oral fluids, or other patient materials;2) Indirect contact with contaminated objects (e.g., instruments, equipment, or environmental surfaces);3) Contact of conjunctival, nasal, or oral mucosa with droplets (e.g., spatter) containing microorganisms generated from an infected person and propelled a short distance (e.g., by coughing, sneezing, or talking); and4) Inhalation of airborne microorganisms that can remain suspended in the air for long periods
8 Conditions Necessary For Infection To Occur A pathogenic organism of sufficient virulence and in adequate numbers to cause disease;A reservoir or source that allows the pathogen to survive and multiply (e.g., blood);A mode of transmission from the source to the host;A portal of entry through which the pathogen can enter the host; andA susceptible host (i.e., one who is not immune)
9 Standard Precautions Standard precautions apply to contact with: 1) blood;2) all body fluids, secretions, and excretions (except sweat), regardless of whether they contain blood;3) non-intact skin; and4) mucous membranes.Saliva has always been considered a potentially infectious material in dental infection control; thus, no operational difference exists in clinical dental practice between universal precautions and standard precautions.Standard precautions include use of PPE (e.g., gloves, masks, protective eyewear or face shield, and gowns) intended to prevent skin and mucous membrane exposures. Other protective equipment (e.g., finger guards while suturing) might also reduce injuries during dental procedures
11 Hierarchy of ControlsEngineering controls that eliminate or isolate the hazardpuncture-resistant sharps containers andsafety sharp devices are the primary strategies for protecting DHCP and patientsWork-practice controls that result in safer behaviorsone-hand needle recappingnot using fingers for cheek retraction while using sharp instruments or suturing and use ofPersonal protective equipment (PPE)protective eyewear, gloves, and mask
13 Preventing Exposures to Blood and OPIM Use standard precautions (OSHA's bloodborne pathogen standard retains the term universal precautions) for all patient encountersConsider sharp items (e.g., needles, scalers, burs, lab knives, and wires) that are contaminated with patient blood and saliva as potentially infective and establish engineering controls and work practices to prevent injuriesImplement a written, comprehensive program designed to minimize and manage DHCP exposures to blood and body fluids
14 Exposure Vrs Exposure Incident Reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee's dutiesExposure IncidentThrough percutaneous injury (a needlestick or cut with a sharp object),Through contact between potentially infectious blood, tissues, or other body fluids and mucous membranes of the eye, nose, mouth,Non-intact skin (exposed skin that is chapped, abraded, or shows signs of dermatitis)
15 Percutaneous Injuries 1) Occur outside the patient's mouth, thereby posing less risk for re-contact with patient tissues;2) Involve limited amounts of blood; and3) Are caused by burs, syringe needles, laboratory knives, and other sharp instrumentsInjuries among oral surgeons occur more frequently during fracture reductions using wiresExperience does not affect risk of injury among general dentist or oral surgeon
16 Engineering ControlsThe primary method to reduce exposures to blood and OPIM from sharp instruments and needlesAre frequently technology-based and often incorporate safer designs of instruments and devicesself-sheathing anesthetic needlesdental units designed to shield burs in handpieces to reduce percutaneous injuries
17 Work Practice Controls Establish practices to protect DHCP whose responsibilities include handling, using, assembling, or processing sharp devices (e.g., needles, scalers, laboratory utility knives, burs, explorers, and endodontic files) or sharps disposal containers.can include removing burs before disassembling the handpiece from the dental unit,restricting use of fingers in tissue retraction or during suturing and administration of anesthesiaminimizing potentially uncontrolled movements of such instruments as scalers or laboratory knives
18 Work Practice Controls for Sharps Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers located as close as feasible to where the items were usedNever recap used needles or otherwise manipulate by using both hands, or any other technique that involves directing the point of a needle toward any part of the bodyUse a one-handed scoop technique, a mechanical device designed for holding the needle cap to facilitate one-handed recapping, if an engineered sharps injury protection device is not available or appropriate for recapping needles between uses and before disposalNever bend or break needles before disposal because this practice requires unnecessary manipulationFor procedures involving multiple injections with a single needle, the practitioner should recap the needle between injections by using a one-handed technique or use a device with a needle-resheathing mechanism.Passing a syringe with an unsheathed needle should be avoided because of the potential for injury.
20 Personal Protective Equipment Designed to protect the skin and the mucous membranes of the eyes, nose, and mouth of DHCP from exposure to blood or OPIM..
21 Personal Protective Equipment Gloves, surgical masks, protective eyewear, face shields, and protective clothing (e.g., gowns and jackets).All PPE should be removed before DHCP leave patient-care areasReusable PPE (e.g., clinician or patient protective eyewear and face shields) should be cleaned with soap and water, and when visibly soiled, disinfected between patients, according to the manufacturer's directionsWearing gloves, surgical masks, protective eyewear, and protective clothing in specified circumstances to reduce the risk of exposures to bloodborne pathogens is mandated by OSHAGeneral work clothes (e.g., uniforms, scrubs, pants, and shirts) are neither intended to protect against a hazard nor considered PPE
22 Masks, Protective Eyewear, Face Shields A surgical mask that covers both the nose and mouth and protective eyewear with solid side shields or a face shield should be worn during procedures and patient-care activities likely to generate splashes or sprays of blood or body fluids.The mask's outer surface can become contaminated with infectious droplets from spray of oral fluids or from touching the mask with contaminated fingers
24 Gloves and GlovingWear gloves to prevent contamination of hands when touching mucous membranes, blood, saliva, or OPIMReduces the likelihood that microorganisms present on the hands will be transmitted to patients during surgical or other patient-care proceduresMedical gloves, both patient examination and surgeon's gloves, are manufactured as single-use disposable items that should be used for only one patient, then discarded.Gloves should be changed between patients and when torn or puncturedWearing gloves does not eliminate the need for handwashingGloves can have small, unapparent defects or can be torn during use, and hands can become contaminated during glove removalIn addition, bacteria can multiply rapidly in the moist environments underneath glovesThe hands should be dried thoroughly before donning gloves and washed again immediately after glove removal.
25 OSHA On Sharps 2001-Revised Bloodborne Pathogens Standard Clarify the need for employers to consider safer needle devices as they become available and to involve employees directly responsible for patient care (e.g., dentists, hygienists, and dental assistants) in identifying and choosing such devices
27 800,000 Needlestick Injuries Occur Each Year in the United States SLIDE #4: (800,000)It may surprise you to learn that there are an estimated 800,000 needlestick injuries each year in the U.S...
28 Needlestick Injuries Are Underreported by Health Care Workers Reasons for underreporting:Lack of timeEmployer responseFear of HIV
29 Viral Hepatitis - Overview Type of HepatitisABCDESource offecesblood/blood/blood/fecesvirusblood-derivedblood-derivedblood-derivedbody fluidsbody fluidsbody fluidsRoute offecal-oralpercutaneouspercutaneouspercutaneousfecal-oraltransmissionpermucosalpermucosalpermucosalChronicnoyesyesyesnoinfectionpre/post-Preventionpre/post-blood donorpre/post-ensure safeexposureexposurescreening;exposuredrinkingimmunizationimmunizationrisk behaviorimmunization;watermodificationrisk behaviormodification3
30 HIV You might have HIV and still feel perfectly healthy The only way to know for sure if you are infected or not is to be tested
31 Relative Risks of Infection After Exposure HBV %HCV Average 1.8%HIV Average 0.3%
32 Do Safer Needle Devices Prevent Injury? Can’t eliminate all, but…83% can be preventedSLIDE #34: (Do safer needle devices prevent injury?)All needlestick injuries are not preventable, but research has shown that almost 83% of injuries from hollow bore needles can be prevented (Ippolito et al, 1997). Many of these needlesticks can be prevented by using devices which have needles with safety features or eliminate the use of needles altogether (e.g., needleless IV systems, self re-sheathing needles, blunted phlebotomy needles, and blunted surgical needles).Most current research is hospital based and studies have indicated that a significant portion of needlestick injuries occur when manipulating IV lines or administering IV and IM injections (Jagger, 1988). In 1992, the FDA published a safety alert regarding the use of hypodermic needles as a connection between two pieces of IV equipment. The FDA said that secondary IV tubing with connector needles was associated with the highest risk of needlestick injury. The use of needleless IV systems or systems with recessed needles to connect adjoining equipment was strongly encouraged in this alert .Source: Ippolito, et. al., 1997
36 Engineered Sharps Injury Protection Identify, evaluate, and select devices with engineered safety features at least annually and as they become available on the market (e.g., safer anesthetic syringes, blunt suture needle, retractable scalpel, or needleless IV systems)
37 Sterilization/Disinfection Single-use disposable instruments are acceptable alternatives if they are used only once and disposed of correctlyEnsure that reusable equipment is decontaminated with a tuberculocidal EPA-registered disinfectant
40 Sterilization/Disinfection Designate a central processing areaTrain employees to use proper work practices to prevent contamination of clean areasMinimize handling of loose contaminated instruments during transport to processing area and carry instruments in a covered containerClean all visible blood and other contamination from instruments and devices before sterilization or disinfectionMinimize contact with sharp instruments if manual cleaning is necessary—NEVER reach by hand into containers of contaminated instruments/devices
44 Regulated WasteDiscard contaminated items in leak-proof labeled containerDisposed of according to Tennessee Department of Environment and Conservation Rules( )
45 Hepatitis B Vaccination Take the vaccination that is offered to youIt is safe and effective and freeFollow U.S. Public Health Service GuidelinesHBV Vaccinations“ Immunization of Health Care Workers: Recommendations of ACIP and HICPAC,” MMWR, Vol. 46, No. RR-18, December 26, 1997Declination statement
46 Hepatitis B Vaccination Antibody testing 1-2 months after completion of 3-dose seriesDHCP should complete a second 3-dose vaccine series or be evaluated to determine if they are HBsAg-positive if no antibody response occurs to the primary vaccine series (IA, IC) Retest for anti-HBs at the completion of the second vaccine series. If no response to the second 3-dose series occurs, non-responders should be tested for HBsAg (IC) Counsel non-responders to vaccination who are HBsAg-negative regarding their susceptibility to HBV infection and precautions to Provide employees appropriate education regarding the risks of HBV transmission and the availability of the vaccine. Employees who decline the vaccination should sign a declination form to be kept on file with the employer
47 Post-Exposure Follow-ups Report all exposure incidentsHealth care professional's written opinionHBVFollow-up
48 Training--Annually Five Easy Questions What is universal precautions? What do you do when there is a blood spill?Personal protectionClean-up and disposal proceduresDisinfection (hazard communication applies)What do you do with contaminated sharps and laundry?Have you been offered the HBV vaccination free of charge?Where is the Exposure Control Plan?
49 Exposure Control Plan Must be in writing Must include Exposure DeterminationMust be reviewed and updated annuallyPlan must be updated to reflect changes in technology that eliminate or reduce employee exposurePlan must document consideration and implementation of appropriate, commercially available and effective engineering controls
50 Exposure Control PlanEmployer's plan describing how compliance with the standard is achievedDescribes what employees are coveredDescribes tasks that are coveredDescribes post-exposure follow-up proceduresMust be reviewed and updated annuallyMust be accessible to employeesSee Journal of the Tennessee Dental Association, Fall 2007
51 Call TOSHA for Help Memphis Office 901-543-7259 Jackson OfficeNashville OfficeKnoxville OfficeKingsport OfficeChattanoogaConsultative Services
52 Web Resources Federal OSHA-www.osha.gov TOSHA-www.tennessee.gov/labor-wfd/toshaCenters for Disease Control-National Institute of Occupational Safety and Health-www.cdc.gov/niosh