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

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

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

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

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

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

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]

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

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

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

Instrument Reprocessing and Sterility Assurance

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

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

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

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

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

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

Prevention Strategies Engineering controls Personal protective equipment Work practice controls

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

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

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

Safe Instrument Handling for Processing

Instrument Transport Containment The Container PPE Labeling

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

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

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

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

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

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

Principle Always clean before sterilization

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

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

Methods: Handscrubbing Infection Control and Safety Considerations PPE Injury Prevention

Instrument Packaging Principle Materials/products Process Labeling

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

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

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)

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)

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!

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

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.

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)

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

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

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

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

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

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

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

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

Space Considerations and Flow Efficiency in Instrument Processing

Sterilization Monitoring Mechanical/Electronic Chemical Indicators/Integrators Biological Indicators (spore tests)

Mechanical/Electronic Controls Observation of gauges, and indicators on the sterilization equipment. (cycle monitors) Time Temperature Pressure Etc.

Chemical Indicators Examples: FDA: Class 1 – 5 depending on quality! Color change indicators printed directly onto packaging (i.e. pouches). Indicator Tape Indicator Strips Indicator Labels FDA: Class 1 – 5 depending on quality!

Biological Indicators Processing nonpathogenic spore organisms impregnated on a strip or in a glass vial to verify sterility by killing bacterial endospores.

Biological Indicators (BI) Bacillus stearothermophilus Steam and chemical vapor sterilization Bacillus subtilis Dry heat and ethylene oxide sterilization

How to Spore Test Select a BI that is FDA cleared for use with your sterilization process. Unwrapped – place in the center of the load. Wrapped – place inside a pack in the center of the load or over the drain of a large unit. Do not put the control strip/vial in the sterilizer.

Types of BI Systems In-Office Vials Incubator Record book

Types of BI Systems Mail-In Service 3rd Party Verification Dental School Commercial Lab 3rd Party Verification

Rapid Enzyme Indicators

CDC Guidelines state… “Proper functioning of sterilization cycles should be verified by the periodic use (at least weekly) of biological indicators (i.e. spore tests).” May 28, 1993

Causes of Sterilization Failure and Troubleshooting

Sterilization Failure Improper Cleaning of Instruments Improper Packaging Materials Improper Loading of the Sterilizer Improper Sterilization Parameters Time Temperature And/or pressure Improper Selection of Sterilization Method

What to do if there is a sterilization failure.

Positive Spore Test: Failure Do not recall instruments, other than implantable devices, because a single positive spore test unless the sterilizer or sterilization procedure is obviously dedfective (e.g., incorrect mechanical or chemical indicator readings Recall ( as far as possible) and reprocess all items from a suspect load(s) if a second spore test remains positive for bacterial growth

Handling and Transport of Processed Sterile Packages

Storage of Packaged Sterile Instruments

Considerations Location Environmental storage conditions Cool Dry Clean

What is the shelf-life of a sterilized package of instruments?

“Event Related” Policy Maintain integrity of the package as a barrier Keep the package material dry Do inventory checks for damaged packaging material Repackage and re-sterilize damaged packages before use.

Events that Compromise the Packaging Material Moisture Wet packages out of sterilizer due to inadequate dry time Moist storage conditions Torn, ripped, punctured, crushed, rupture of seals and closures, opened packages Handling and transport Poor organization of storage area

Chairside Marketing of the Sterilization Program Always open the package of sterile instruments in front of the patient.

Other Considerations?

Instrument Protection Considerations and Recommendations

Dental Handpieces Considerations Semi-critical dental devices that touch mucous membranes that are attached to the air and /or waterlines of the dental unit Follow Manufacturers’ Directions

Dental Handpieces High speed handpieces Slow-speed handpieces Prophy angles Ultrasonic and sonic scaling tips Air abrasion devices Air and water syringe tips

Handpiece Infection Control Clean and treat dental handpieces and other intraoral instruments, that can be removed from air and/or waterlines of dental units, with a sterilization process that uses heat e.g., steam, dry heat, unsaturated chemical vapor Sterilize between each patient Follow manufacturer’s directions for maintenance and compatibility of the handpiece with sterilization method(s) Also consult the manufacturer of the sterilizer and mechanical cleaning devices for compatibility with specific dental handpieces

Instrument Processing and Sterility Assurance Cost Effective Product and Equipment Selection

Instrument Processing Work Flow and Design for Safety and Efficiency Choosing the Right Strategy for Your Practice Following the principles of infection control and related health and safety

Sterility Assurance - Components of Instrument Processing Biologic debridement Cleaning, Packaging, Sterilization Sterilization Monitoring Appropriate Storage Inventory Management Personnel Management

Sterility Assurance Adequate and properly functioning equipment and products Properly trained personnel who behave in a manner consistent with policies, procedures and product directions Adequate space, design and flow of the reprocessing area to facilitate efficiency and safety

Dental Unit Water Quality What is in your water? The Problem(s) Solutions Recommendations Regulations?

Water Quality Potable water: Dental unit water 10k - 100k, ...CFU/ml Less than 500 CFU per ml. of water and 0 coliforms Dental unit water 10k - 100k, ...CFU/ml Why? The American Dental Association statement and challenge to industry Develop methods to control biofilms in dental unit water systems Goal : heterotrophic bacteria should not exceed 200 CFU/ml in unfiltered output

Sources of DUWL Contamination Source water Retracted oral fluids? Biofilm formation in the dental unit waterline

Conditions that Facilitate Biofilm Formation in the DUWL Low numbers of microbes continually enter the line/tubing Nutrients are continually being supplied in the incoming water Stagnation of the water in the tubing facilitate accumulation The waters natural flow rate is low near the tubing walls

Conditions that Facilitate Biofilm Formation in the DUWL (con’t.) Water in the tubing is now under high pressure The tubing is not under high pressure The tubing’s small diameter creates a large surface-to-volume ratio

Health Implications No definable health risks (limited epidemiologic data) However, the the high CFU in DUWL is a sanitation concern at minimum

Dental Unit Water Quality Centers for Disease Control and Prevention (CDC) recommendations American Dental Association (ADA) recommendations Office Safety and Asepsis Procedures (OSAP) Positions Paper ISO standards Other?......

Solutions and Currently Available Technology

Reduce the Microbial Contamination Source Water: Improve the quality of the incoming water Waterlines: Control the biofilm in the tubing Output Water: Control water quality as it leaves the tubing

Available Technology Independent reservoirs Chemical treatment Continuous Intermittent Sterile water delivery systems Filtration Combined

Resource for Dental Unit Quality Information Organization for Safety and Asepsis Procedures in Dentistry (OSAP) www.osap.org Dental Unit Water Quality Focus Complete resource of information, scientific literature, CDC and professional recommendations and available technology

From Policy to Practice Site-specific application of policies Standard operating procedures Day -to- Day management of policies and procedures

Education and Training Techniques Tools Centers for Disease Control and Prevention (CDC) Recommendations, OSHA Regulations others Organization for Safety and Asepsis Procedures (OSAP) Institutional Policies and SOP for each practice setting Resources (related guidelines, standards, regulations and statutes) Approaches ( talking vs teaching vs training)

Compliance Assessment / Evaluation Feedback and Reflection Assuming responsibility for health and safety of patients/clients, yourself and other staff Ethical Legal Enforcement Positive reinforcement Negative reinforcement

Resources Recommendations Centers for Disease Control and Prevention (CDC) www.cdc.gov National Institutes of Occupational Safety and Health (NIOSH) www.cdc.niosh.gov Professional Recommendations ( OSAP www.osap.org ADA www.ada.org ADHA www.adha.org ADAA www.adaa.org

Resources (continued) Regulations/statutes State Boards of Registration State Departments of Public Health State /local agencies who regulate waste Biohazard, chemical, general

Kathy Eklund Motto for Infection Control and Health and Safety Learn the concepts, keep current with the science and relevant standards Believe that it is critical to healthcare delivery Behave in a manner consistent with the above