INFECTION+CONTROL+2010

Magda Schwarz 2009 1

OTC INFECTION CONTROL 2010

STANDARD PRECAUTIONS

apply to all patients treated to minimize risk of cross infection from dentist to patient, from patient to dentist and patient to patient.

Hand washing with water and detergent prior and after physical contact with the patient

PPE Personal Protective Equipment (mask, Gloves, gown and protective glasses)

Management of blood contaminated items and sharps management to prevent sharp injury.

Immunization of health care workers (not compulsory though) Aseptic techniques when performing all sterile procedures9 sterile drapes,

gloves etc) Routine environmental cleaning Management of waste; blood contaminated gowns into clear plastic bag

and cloth bag outside) Minimizing aerosol spray -using rubber dam whenever possible, oral

evacuation- high and low volume suction used for the procedures; and flushed between every patient and sanitized at the end of the day.

Apply to all patients including HIV , Hep A, B, C, conjunctivitis, herpes simplex

ADDITIONAL PRECAUTIONS

For patients suspected or diagnosed with airborne transmission (Mycobacterium tuberculosis, chicken pox, bronchiolitis, haemophilus influenza, rubella) droplet transmission (rubella, pertussis, influenza) and patients having open purulent wounds with exfoliative dermatitis.

Separate treatment room if possible Not rostering immunocompromised health care worker to treat the patient

dedicated patient specific equipment if possible, restricted patient movement and cohorting

Treatment at the end of the day High filtration mask 0.3 microns


Apply to all mentioned above and anthrax, cholera, croup, dermatitis, diphtheria, encephalitis, epiglottitis, heamorrhagic fevers, herpes zoster, bacterial meningitis, mumps, poliomyelitis, scabies, Vancomycin resitant enterococci, MRSA

Elective dental procedures should be deferred until patient is not actively infectious (not applicable to cCJD). If treatment is urgent, the following additional precautions are applied and should be adapted to the particular infectious agent involved and the mode of transmission

CJD

The Commonwealth Department of Health and Ageing released an update in December 2007 to the Infection Control Guidelines for the prevention of transmission of infectious diseases in the health care setting regarding the recommendations for treating patients at risk of classical Creutzfeldt-Jakob Disease (cCJD) infection, including treatment in the dental setting. The application of additional precautions to minimize the risk of transmission of cCJD is based on a risk assessment. The tissues or body fluids likely to be exposed during a procedure are classified as Higher-infectivity or Lower-infectivity. In dental procedures, all general practice dentistry now deals with tissues assessed as Lower-infectivity, i.e. oral tissues (teeth, gingival tissues, dental pulp), peripheral nerves, and saliva.

In all patients, dental procedures involving exposure to Lower-infectivity tissues should now use routine reprocessing precautions (Standard Precautions). Additional precautions are no longer required.

The previously classified high-risk procedures of endodontic procedures and any maxillofacial surgery procedures where contact may be made with branches of the cranial nerves and their main peripheral sensory extensions are now classified as Lower-infectivity. Oro-facio-maxilliary surgical procedures that come into contact with Higher-infectivity tissues in patients of high- or low- risk should be treated with additional precautions. These procedures would include: Major oral surgery procedures such as a maxillectomy involving orbit enucleation; Injection of the trigeminal ganglion; Oral surgical cancer procedures also combining a neurosurgical approach which would involve exposure to tissue of higher-infectivity.


SURGERY LAYOUT:

Areas: clerical (desk), work (chair), clean and dirty side, hand-washing sink. Yellow plastic bags - for blood contaminated items (gauze, cotton rolls, gloves, floss bibs, etc.). Sharps container - for the safe disposal of local anaesthetic needles, suture needles, scalpel blades, metal matrix bands, and slow speed burs, wedges,, pins used local anaesthetic cartridges, endo needles and syringes, endodontic files, reamers, broaches, broken instruments.

Sharps container should be puncture proof, non reusable (AS 4031) or reusable (AS/NZS 4261) yellow container with black biohazard sign; must be fixed on the wall or trolley with the opening easily accessible for the operators. Never on the floor as children may access the sharps. The container is sealed when 2/3 full and send out to the disposal site.

Plastic barriers - for covering of the suction unit, bracket table, hand pieces and triplex syringe, headrest, and lamp handles.

SURGERY-SET UP Q: Clinic closed for the holiday: what should be done before seeing the patients (the answer depends on the photograph shown)

damp dusting and ? mopping floors chair: surface cleaning from high to low with clean cloth and appropriate

detergent and hot water. Waterline asepsis: once a week or before first patient

5.25%hypochlorite diluted 1:10 with tap water (do not use White King-corrosive and foaming), fill the wet bottle with 100 ml of the solution shake and stand for 10 minutes. Discard. Fill the bottle with 750 mls of the solution , install into the unit and flush the lines for 15-20 sec so the solution flows through all lined (hand piece, scaler and triplex); allow to stand 10-30 minutes and purge unit with air allowing all the solution to go through the lines.

install distill water bottle, flush all lines for 2 minutes (always done at the start of the day)

Plastic wraps ,single use items as appropriate Instruments ready as required. Unlock the cabinet with drugs-LA


Instruments: resterilize if the shelf life expired.

SURGERY SHUT DOWN FOR THE DAY: Dispose waste; remove dirty instruments to steri room for processing, Run small amount of water through suction before removing the tip and wraps Flush all waterlines for 30 secs Spittoon basket is emptied to clinical waste and the filter is replaced at least weakly. Rinse the suction lines with water and the hypochlorite solution (ALproJet- 50 mls of concentrate mixed with 950 ml of water. Remove all the plastic barriers. Install empty bottle and purge all the lines for 30 secs Wipe the chair with roar (disposable cloth) and detergent (no sprays as this created aerosols and OH&S hazard). Turn of the unit, store consumables instrument as require. Lock the LA solutions and other medicaments in the locked cabinet (schedule S4 poison)

INSTRUMENTS:

All instruments used on the patients must be either single use or sterilized and sterile at the point of use. We do not use cold sterilization: -soaking the non autoclavable instruments in glutaraldehyde and formaldehyde solutions (carcinogens, skin and eye burns, and asthmagenics)

Critical instruments: penetrating through skin or mucosa, bloodstream or sterile cavity (e.g. scalpel, needle, matrix band, Roth band, files)

Semi critical instruments: contact with intact skin or mucosa (exam instruments, hand pieces, triplex syringe, ultrasonic scalars)

Non critical: benches, chair etc.

PPE: PERSONAL PROTECTIVE EQUIPMENT

Gowns - MUST NOT be worn outside Clinic. Protective glasses with side shields are required to be worn for all procedures when splashing may occur. Protective dark glasses for the patient must be available in the clinic. Prescription glasses must be fitted with side shield.


Masks - high filtration, single use masks are available in the clinic, and must be worn for every procedure where splashing and aerosols may occur. This also includes examination of the patient. Mask should be change if exposed for more than 20 minutes of aerosol spray. Or at the end of the procedure Masks MUST NOT be worn around neck or outside the Clinic. Masks are to be worn beneath full face shield Gloves must be worn whenever it is likely that contact with body fluids, or other contaminated materials (i.e. dentures, impressions, etc.), may occur. Gloves are for single use only. They must be changed if punctured, and under NO CIRCUMSTANCES should they be washed and reused.

DO NOT touch hair, mask, glasses and areas not covered with barrier plastic whilst wearing gloves.

DO NOT open the cupboard and get instruments with gloves on - ask DA someone to help you. Or use plastic wraps over the handles and have patient dedicated transfer tweezers.

TYPES OF GLOVES- in different sizes Standard non sterile powder free examination gloves for routine procedures (latex) and latex free gloves for sensitive patient of health care workers (nitrile gloves-blue) Sterile single use powder free latex and latex free gloves for all sterile procedures (minor oral surgery) Heavy duty rubber gloves for cleaning dirty instruments and routine environmental cleaning.

STERILIZATION:

Process intended to kill or remove all types of organisms including spores.

Types of sterilization process: steam under pressure (moist heat)-preferred dry heat ethylene oxide, hydrogen peroxide plasma and automated environmentally sealed low temperature peracetic acid. irradiation,


Sterilizers:

Downward(gravity)displacement- air is drawn downward by gravity by incoming steam; flash sterilizers for emergency instruments belong to that group; good for unwrapped and non porous instruments

usually class N autoclaves Self contained (benchtop) - air removal utilizes one or more vacuum

stages together with positive pulses of steam. Good for processing complex or cannulated instruments.

Include: a) positive pressure displacement autoclaves and b) negative pressure displacement autoclaves (class S) Prevacuum - air is removed from the chamber and the load by vacuum

pump prior to the admission of steam; steam penetrates better and drying cycle is more efficient ( triple vacuum autoclaves class B)

Operator convertible

AS/NZS 4815:2006, the Australian Standard governing autoclave use in office based practices assigns three different classes for autoclave sterilization cycles. These are: Type B cycle (the strictest), Class S cycle and Class N cycle (the least strict) AUTOCLAVE CYCLE DEFINITIONS (www.autoclave.com.au) Type B cycle A cycle capable of sterilizing all wrapped (single or double) or unwrapped items, including porous and cannulated items that do not exceed the specifications of Hollow load Type A.

Type S cycle A cycle capable of sterilizing unwrapped items and at least one of the following load types: porous items, small porous items, Hollow load Type A, Hollow load Type B, single layer wrapped items, double wrapped items.

Type N cycle A cycle capable of sterilizing unwrapped, solid items

WHAT ARE TYPE A & B HOLLOW INSTRUMENTS?

Hollow Load Type A An object whose ratio of length of cavity to diameter is greater than 5.


Due acknowledgement is given to EN 13060:2004.

Hollow Load Type B An object whose ratio of length of cavity to diameter is greater than 1 and less than 5.


Non Hollow Instruments An object whose ratio of length of cavity to diameter is less than 1.



Critical and semi critical instruments from point of use to storage; Dispose waste and single use items and segregate instrument to be

sterilized (e.g. trays) All instruments collected form the bracket table and transported to dirty

bay/sterilization room in rigid plastic container with the lid. Washing: under running water to remove blood and debris Dismantle all complex instruments Non immersible instruments (hand pieces, cavitron) are dismantled, wiped with detergent, lubricated as required, and packaged

Immersible instruments are soaked, washed in ultrasonic washer, then scrubbed with brush in the water with detergent, rinsed in the hot water and dried

Inspection: Instruments are inspected for cleanliness (of visible contamination) complete and function.

Packaging-Instruments packed to cassettes and wrapped into blue Kim guard or sealed in the steri pouches.

All items batch labeled: method of sterilization, sterilization unit ID number, and date of sterilization, cycle or load number.

Sterilization process-all items must be dried when removed form the autoclave.

The person unloading the autoclave is responsible for checking if the cycle was according to the prescribed parameters (time, temperature and pressure)

Holding Times Plus Safety Factor 0C kPa mb Psi Holding time plus safety factor(mins) 121 103 1030 15 15 126 138 1380 30 10 132 186 1860 27 4 134 203 2030 30 3

Above table illustrates the approximate temperature-pressure relationship for effective steam

Shelf life- safe up to 28 days (DHSV policy)

All items dropped, compressed with punctured packaging or pouches not sealed are reprocessed and must not used on patients.


Ultrasonic Cleaning Ultrasonic cleaners shall comply with AS2773.2:1999.

Daily Validation Testing (Pencil Load Test) Rub the surface of an unglazed ceramic disc or plate having a matt finish and a diameter of approximately 50 mm (thickness is not critical) with a standard HB pencil lead and then immerse the disc in the ultrasonically agitated tank. A ground glass stopper, a sheet of ground glass or an aluminium sheet with a thickness of 2mm to 3mm may be substituted for the ceramic disc. Daily testing should occur at finish of day in order for ultrasonic tank to be drained and thoroughly cleaned to remove residue.

Ultrasonic cleaners are used to assist in cleaning jointed and serrated stainless steel instruments. In general, cannulated instruments (unless specified by manufacturers), plastics, and other similar materials may not be successfully processed by this method.

Cemented glass syringes and lenses will be damaged if repeatedly subjected to this process as the cement dissolves. All visible gross soiling should be removed prior to immersion of the equipment. Ultrasonic washers do not remove soiling. Ultrasonic cleaners work by subjecting instruments to high frequency, high energy sound waves, causing soil to be dislodged from instruments and drop to the bottom of the tank, or sufficiently loosened, to be removed during the rinsing process.

Tracking:

With the batch label permits the linking of packaged sterilized items to a sterilizer cycle within which it was processed. All batch labels are to be place in the patients dental records in case of claims.

Methods of tracking; Double sided batch labels that identify the actual item and can be adhered

to a tracking chart in the patient dental record on the day of the procedure. Manual documentation of equipment used and the sterilizer cycle and

number that the item was processed in. Computerized systems using bar codes

PROSTHETICS: decontamination


Study models and articulated models are regarded as client records and therefore should not be handled with contaminated gloves.

Impressions or other prosthetic appliances, e.g. wax rims, are cleaned immediately after removal from the mouth by rinsing with running water, washing with enzymatic detergent and further rinsing, until all traces of blood and debris are removed. Items are dried.

Reusable metal trays, rubber bowls and spatulas are washed with enzymatic detergent, rinsed, dried and sterilized.

When casting impressions, rubber bowls and spatulas are washed with enzymatic detergent, rinsed, dried, and sterilized.

All materials going to dental laboratories must be decontaminated and placed into a sealed container. The prosthetic equipment and material must be managed so that contamination of other areas does not occur.

Reusable containers must be washed in warm detergent and water. The method of cleaning / decontamination should be documented on the

laboratory form.

MANAGEMENT OF BLOOD SPILL:

Standard precautions apply PPE Spills should be contained and cleared. Avoid creating aerosols Management depends on nature of spill (blood, vomit, and urine), size, surface affected, area, potential of contact with naked skin and potential of pathogen presence. Small spills wiped with paper towel, washed with water and detergent and area dried. Large spills-contain spill with granular hypochlorite based product (name?), collect with scraper and pan, empty into leak proof bag ad clean the surface as above. If spill occurred on the carpet-professional carpet cleaning should be arranged.


NEEDLE STICK INJURY: Stop the procedure and remove gloves. Wash the wound with water and soap and promote bleeding Explain to the patient what happened and ask to provide a blood sample for testing (serum for storage, HEP b surface antigen, HEP C antibody and HIV antibody) with patients consent Document incident and patient consent in the dental records. Give blood sample for serum for storage, HEP B surface antibody level if the dentist was immunized. Blood samples should be taken immediately arrange with the closest GP or Melbourne Pathology lab. Notify the Infection Control Consultant via phone or pager who will notify the recipient and the source about the results within 48 hours. CONFIDENTIAL.

If there is a degree of urgency (patients medical history) the Hep B immunoglobulin should be given within 72 hours and zidovudine within hours from the incident.

If the patient does not consent for blood test or the source is unknown, the recipient should be retested in 3 months from the injury.

WASTE MANAGEMENT:

Teeth: clinical waste Blood contaminated non sharps-clinical waste Sharps; sharps yellow containers All other non blood contaminated waste-general waste Amalgam waste/scrapes: stored in airtight container under waste fixer to minimize vapour Amalgam capsules: airtight container. Fixer and developer: require regulation from local water board and /or sewerage authority to be disposed directly via sewerage system; otherwise through approved disposal firm (contact The Photographic and imaging Council of Australia for liquid waste management. Lead foil: sold to scrap metal dealer or disposed through licensed waste management services. Old films- silver recovery firm.


STAFF VACCINATION

On commencement of employment, all clinical staff is offered Hepatitis B vaccination. Clinical staff is requested to confirm past immunization details on employment. Post-serological testing for the presence of Hepatitis B antibodies is advised. This should occur 3 months after completion of Hepatitis B immunization. .

2. MEASLES, MUMPS, RUBELLA VACCINE (MMR) Two doses of MMR are required. The doses should be given one month apart. Adults born after 1970 should also have evidence of having received two doses of MMR. As this vaccine is live, inoculated staff should avoid contact with immunosuppressed and pregnant patients for a period of one month following inoculation.

3. TETANUS Tetanus vaccination is part of the standard childhood vaccination schedule. Young adults who have received 5 doses in their first 5 years of life should have a further dose at 15 19 years. Those who have received a primary booster of 3 doses as adults should receive 2 booster doses at 10 yearly intervals. A booster dose is recommended at age 50 unless a booster dose has been documented within 10 years. Adult Diphtheria Tetanus (ADT) vaccine should be given in preference to Tetanus Toxoid unless contraindicated. For additional guidelines in the event of a Tetanus prone injury refer The Australian Immunization Handbook 8th Edition 2003 NH&MRC.

4. VARICELLA All clinical staff should be aware of immune status. Vaccination is recommended for seronegative staff. As this vaccine is live, inoculated staff should avoid contact with immunosuppressed and pregnant patients for a period of one month following inoculation.

XXXXXXXX There is no mandatory requirement for healthcare workers to be tested for Hepatitis B (HBV), Hepatitis C (HCV) and Human Immunodeficiency Virus (HIV). Although, healthcare workers undertaking exposure prone procedures have an ongoing responsibility, both professionally and ethically, to know their infectious status for blood borne diseases.

There is no consensus on how often regular testing should be carried out but it should, as a minimum, be performed following blood / sharp exposure injuries. All


health care workers should assess their individual risk of exposure to blood borne viruses, including HIV, HBV, and HCV, and seek voluntary testing where appropriate. Exposure prone procedures, in the broad sense, are considered to be any situations where there is a potentially high risk of transmission of blood borne disease between healthcare workers and patients during medical and dental procedures.

If a staff member is found to be, or volunteers information regarding their positive status for HIV, HCV, or HBV, confidentiality must be maintained. Decisions regarding working practices a healthcare worker infected with a blood borne virus are complex. An infected health care worker must seek confidential advice from a relevant medical physician, such as an Infectious Diseases Consultant, to determine which procedures are safe to perform or assist in. The treating Medical Practitioner may seek expert opinion to assist them by requesting the Department of Human Services to convene an expert panel. Modifications to work practices recommended by the Infectious Diseases Consultant must be adhered to. The treating Medical Practitioner should not notify employers of the blood borne virus status of the healthcare worker unless the healthcare worker gives their consent for this to occur. The decision to inform the Dental Practice Board of Victoria, or not, rests with the individual clinician.

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INFECTION+CONTROL+2010