84 page DENTISTRY INFECTION CONTROL Presentation on CD

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INFECTION CONTROL FOR DENTISTRY, 85 pages (slides)

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INFECTION CONTROL FOR DENTISTRY Abbreviations DHCP – Dental Health-Care Personnel EPA – Environmental Protection Agency FDA – Food and Drug Administration HBV – Hepatitis B Virus IC – Infection Control ICC/ICRF – Infection Control Committee/Review Function OPIM – Other Potentially Infectious Materials MTF – Medical Treatment Facility PPE – Personal Protective Equipment Why Is Infection Control Important in Dentistry? Both patients and dental personnel can be exposed to pathogens Contact with blood, oral and respiratory secretions, and contaminated equipment occurs Proper procedures can prevent transmission of infections to patients and DHCP Immunizations Substantially reduce the potential for disease transmission to DHCP & patients Essential part of prevention & IC programs Varicella Measles Mumps Rubella Influenza Hepatitis B Work Restrictions Conjunctivitis Diarrheal disease Measles/rubella Pertussis Strep Group A Varicella Viral respiratory illness Shingles/zoster Until no discharge Until symptoms stop About 1 week 5 days after antibiotics 24 hours after antibiotics Until lesions crust Until symptoms resolve Cover lesions/crusted Preventing Transmission of Bloodborne Pathogens Standard Precautions Engineering Controls Work Practice Controls Postexposure Management and Prophylaxis Potential Routes of Transmission of Bloodborne Pathogens Standard Precautions THE SAME IC PROCEDURES ARE USED FOR ALL PATIENTS Assume all patients are potentially infectious Infection control policies are determined by the procedure, not the patient Expanded or Transmission Based Precautions Used with standard precautions to interrupt the spread of certain pathogens Three types Airborne (TB) Droplet (>5 microns) (Influenza) Contact (Herpes) Immunizations 3 dose vaccine Check for antibodies 1-2 months after third dose Revaccinate DHCP who do not develop adequate antibody response Booster does of vaccine and periodic serologic testing to monitor antibody concentration after completion of the vaccine series are not recommended for vaccine responders Hepatitis B Vaccine Engineering Controls Controls that isolate or remove the bloodborne pathogens hazard from the workplace Commonly used in combination with work practice controls and PPE to prevent exposure Follow local MTF policy regarding safety device selection & evaluation procedures Work Practice Controls Practices incorporated into the everyday work routine that reduce the likelihood of exposure by altering the manner in which a task is performed Occupational Exposure Incident Specific eye, mouth, other mucous membrane, non-intact skin or parenteral contact with blood/OPIM (including saliva in dental settings) resulting from performance duties Establish procedure for reporting and evaluating exposure incident Average Risk of Transmission after Percutaneous Exposure to Blood Postexposure Management Wound Care Clean wounds with soap and water Flush mucous membranes with water No evidence of benefit for: application of antiseptics or disinfectants squeezing (“milking”) puncture sites Avoid use of bleach and other agents caustic to skin Postexposure Management: The Exposure Report Date and time of exposure Procedure details…what, where, how, with what device Exposure details...route, body substance involved, volume/duration of contact Information about source person Information about the exposed person Exposure management details Postexposure Management Immediate evaluation & follow-up completed by a qualified health-care professional After each incident review circumstances surrounding the injury & the postexposure plan Provide training to implement changes as needed Hand Hygiene The most important means of preventing disease transmission Hand Hygiene Indications When hands are visibly contaminated Before and after treating each patient (e.g., before glove placement and after glove removal) After barehanded touching of inanimate objects likely to be contaminated by blood or saliva Before regloving after removing gloves that are torn, cut, or punctured Before leaving the dental operatory, dental laboratory, or instrument processing area Hand Hygiene Techniques When hands are visibly dirty, contaminated, or soiled non-antimicrobial or antimicrobial soap & water (minimum of 15 seconds) use of liquid soap (vs. bar soap) and hands-free dispensing controls is preferable Hand Hygiene Techniques If hands are not visibly soiled non-antimicrobial or antimicrobial soap & water (minimum of 15 seconds) or alcohol-based hand rub (rub hands until dry) Hand Hygiene Techniques Before an oral surgical procedure: antimicrobial soap and water; scrub hands and forearms for length of time recommended by manufacturer (usually 2-6 minutes) or alcohol-based hand rub with persistent activity: Before applying, pre-wash hands & forearms with non-antimicrobial soap; follow manufacturer recommendations Skin Care Use MTF-approved hand lotions or creams Check compatibility with the manufacturer Some lotions may make medicated soaps less effective Some lotions cause breakdown of latex gloves (e.g., petroleum based) Lotions can become contaminated with bacteria if dispensers are refilled Fingernails, Artificial Nails, & Jewelry Keep fingernails short with smooth, filed edges to allow thorough cleaning and to prevent glove tears Use of artificial fingernails is usually not recommended (Follow MTF policy) Do not wear hand or nail jewelry if it makes donning gloves more difficult or compromises the fit and integrity of the glove Personal Protective Equipment (PPE) Protects the skin & mucous membranes of the eyes, nose, and mouth from exposure to blood or OPIM Use of PPE is dictated by the exposure risk, not the patient Masks and Protective Eyewear Wear a surgical mask and protective eyewear with solid side shields to protect mucous membranes of the eyes, nose, & mouth Change masks between patients, or during treatment if it becomes wet Masks and Protective Eyewear A face shield may substitute for protective eyewear Clean protective eyewear with soap & water or if visibly soiled, clean & disinfect between patients Protective Clothing Wear long-sleeved reusable or disposable gowns, clinic jackets, or lab coats to protect skin of the forearms and clothing likely to be soiled with blood, saliva, or OPIM Change immediately if visibly soiled Protective Clothing Long-sleeved protective clothing is indicated with Use of handpieces Sonic/ultrasonic scaling Manipulation using sharp cutting instruments (e.g., perio surgeries, prophies) Spraying air and water into a patient’s mouth Oral surgical procedures Manual instrument cleaning Gloves Wear when potential exists for contacting blood, saliva, OPIM, or mucous membranes Gloves DO NOT replace the need for hand hygiene Wash hands before donning gloves and upon glove removal Gloves Do not wash gloves before use or for reuse Remove gloves that are cut, torn, or punctured PPE/Laundry Remove all PPE before leaving the work area Do not store contaminated clothing or PPE in lockers or offices Place contaminated laundry in an appropriately labeled container Instrument Processing Cleaning Minimize exposure potential Use carrying containers to transport contaminated instruments from the operatory to the instrument processing area Instrument Processing Cleaning Wear puncture- and chemical-resistant heavy duty utility gloves for instrument cleaning & decontamination procedures Wear a mask, protective eyewear, and long-sleeved protective clothing when splashing/spraying is expected during cleaning Head/shoe covers may be required by MTF policy Instrument Processing Cleaning Clean all visible blood and other contamination from dental instruments and devices before sterilization procedures Instrument Processing Cleaning Automated equipment is preferable to manual hand scrubbing If hand scrubbing is unavoidable, use work practice controls (e.g., long handled brush) & PPE Instrument Processing Preparation & Packaging Before heat sterilization, inspect instruments for cleanliness Wrap or place in packages to maintain sterility during storage Instrument Processing Heat Sterilization Use FDA-cleared medical devices Steam autoclave Dry Heat Unsaturated Chemical Vapor Do not overload the sterilizer Allow packages to dry in the sterilizer before handling Instrument Processing Sterilization Monitoring Monitor each load with mechanical indicators Time Temperature Pressure Instrument Processing Sterilization Monitoring Use an internal chemical indicator in every package. If the internal indicator is not visible from the outside, then use an external indicator Inspect indicator(s) after sterilization & at time of use Instrument Processing Sterilization Monitoring Do not use instrument packs if chemical or mechanical monitoring indicate inadequate processing Instrument Processing Sterilization Monitoring Use biological indicators (spore tests) at least weekly or as directed by MTF policy Autoclave/chemiclave Geobacillus stearothermophilus Dry heat Bacillus atrophaeus Instrument Processing Sterilization Monitoring Spore test every load if performing flash sterilization or sterilizing implantable devices Do not use flash sterilization for reasons of convenience or to save time Instrument Processing Storage Event-related shelf-life: a storage practice that recognizes that a package and its contents remain sterile until some event (e.g., the packaging becomes wet or torn) causes the item(s) to become contaminated Time-related shelf-life: a storage practice where an expiration date is placed on each package Environmental IC Follow manufacturer instructions for correct use of EPA-registered hospital disinfecting products Use appropriate PPE to protect yourself from the chemicals Environmental IC Clinical Contact Surfaces A surface contaminated from patient materials either by direct spray or spatter generated during dental procedures or by contact with DHCP’s gloved hands Environmental IC Use surface barriers to protect clinical contact surfaces, especially those that are difficult to clean Change barriers between patients Environmental IC Clean and disinfect clinical contact surfaces that are not barrier-protected using an EPA-registered intermediate level (tuberculocidal) disinfectant after each patient Environmental IC Clean housekeeping surfaces on a routine basis—depending on nature of surface and contamination & when visibly soiled Environmental IC Regulated Medical Waste Solid waste that is soaked or saturated with blood or saliva (e.g., gauze saturated with blood following surgery) Items that are caked with dried blood or OPIM capable of releasing these materials during handling Extracted teeth Surgically removed hard & soft tissues Contaminated sharp items Note: definitions may vary according to locality Dental Unit Water Quality Use water that meets standards set by the EPA for drinking water (fewer than 500 CFU/mL of heterotrophic water bacteria) for non-surgical dental treatment output water Use sterile solutions for surgical procedures Dental Unit Water Quality Untreated or unfiltered dental unit waterlines are unlikely to meet drinking water standards Measures to Improve Dental Unit Water Quality Independent water reservoir system Allows daily draining and air purging if indicated Allows application of periodic &/or continuous chemical germicides Water purification cartridges/systems Sterile water delivery systems Filtration COMBINATION OF METHODS Measures to Improve Dental Unit Water Quality Independent reservoir advantages Isolates unit from municipal water supply Choice of water source (allows use of water of known quality-e.g., distilled water) Allows use of waterline treatment products Best support in scientific literature when used with waterline treatment products Dental Unit Water Quality Between patients, discharge water and air for a minimum of 20-30 seconds from any dental device connected to the dental water system that enters the patient’s mouth (e.g., handpieces, ultrasonic scalers, air/water syringe) Dental Unit Water Quality In-office testing with self-contained test kits Water laboratory testing using Method 9215 Test each unit quarterly or according to manufacturer instructions Special Considerations Aseptic Technique for Parenteral Medications Use single-dose vials whenever possible Cleanse the diaphragm with 70% alcohol before use Use a sterile device to enter the vial Discard the multidose vial if sterility is compromised Aseptic Technique for Parenteral Medications Do not administer medication from a syringe to multiple patients Do not combine leftover contents of medications for later use Do not use IV fluid sets for more than one patient Contact Dermatitis & Latex Hypersensitivity Screen all patients for latex allergy Develop policies & procedures for evaluation, diagnosis, and management of DHCP with suspected or known occupational contact dermatitis Obtain a definitive diagnosis by a qualified health-care professional (allergist, dermatologist) for any DHCP with suspected latex allergy Contact Dermatitis & Latex Hypersensitivity Provide a latex-safe environment for patients & DHCP with latex allergy Have emergency treatment kits with latex-free products available Dental Handpieces Clean & heat sterilize all handpieces and other intraoral instruments that can be removed from the air and waterlines of the dental unit between patients Dental Laboratory Standard precautions Hand hygiene PPE Clean and intermediate-level disinfect all laboratory items before being worked on in the lab Heat sterilize any items used intraorally or on contaminated appliances Dental Laboratory Communicate cleaning & disinfection procedures Dental Radiology Standard Precautions Hand hygiene PPE (gloves at a minimum) Clean & disinfect equipment or barrier-protect Heat sterilize accessories (film holding devices) Dental Radiology Transport and handle exposed radiographs in an aseptic manner to prevent contamination of developing equipment Digital Imaging General Considerations Equipment difficult, if not impossible, to clean and disinfect Barrier-protect clinical contact surfaces Digital Radiology Sensors Barriers do not always protect the item from potential contamination Since these items are presently not heat-tolerant, at a minimum clean & disinfect with an intermediate level disinfectant after barrier removal Handling Biopsy Specimens During transport, place biopsy specimens in a sturdy, leakproof container labeled with the biohazard symbol Handling Extracted Teeth Regulated medical waste (unless returned to the patient) Do not dispose extracted teeth containing amalgam in regulated medical waste intended for incineration Laser Safety Use standard precautions when working in the area of the laser Wear appropriate PPE including N-95 or N-100 respirators Wear protective laser eyewear Implement local exhaust ventilation controls Tuberculosis Assess all patients for history of tuberculosis Most common symptom=persistent/productive cough Defer elective dental treatment until noninfectious Tuberculosis If patient must be treated: Separate from other patients (have them wear a mask) Refer to area/facility with proper air handling Staff to wear fit-tested N-95 mask Oral Surgical Procedures Incision, excision, or reflection of tissue that exposes normally sterile areas of the oral cavity Examples include: biopsy, periodontal surgery, implant surgery, apical surgery, & surgical extractions of teeth Oral Surgical Procedures Oral Surgical Procedures Conventional dental units cannot reliably deliver sterile water even with an independent water reservoir Use a sterile irrigating syringe, sterile single-use disposable tubing, or sterilizable tubing Preprocedural Mouth Rinses Reduce the level of oral microorganisms in aerosols & spatter May be most useful before procedures using a prophy cup or ultrasonic scaler or before surgical procedures Single-Use (Disposable) Devices Use single-use devices for one patient only and dispose of appropriately Do not clean & sterilize for reuse Summary Effective infection-control strategies are designed to prevent disease transmission & must occur as routine components of practice. Proper procedures can prevent transmission of infections to patients and DHCP. References CDC. Guidelines for infection control in dental health-care settings – 2003. MMWR 2003; 52(No. RR-17):1–66. Available at www.cdc.gov/oralhealth/infectioncontrol. USAF Guidelines for Infection Control in Dentistry, September 2004. Available at https://decs.nhgl.med.navy.mil.