Infection Control Exam Preparation Course Outline – 2017Catherine A. Collier RDH, B.Ed, MS

The information in this handout has been selected by Catherine Collier, RDH, B.Ed, and MS. and is intended only to provide insight into information that may appear on the Infection Control Exam. Course participants are responsible for researching additional course information reflected this handout. The author, Catherine Collier, DOES NOT grant permission to copy or use this course information for teaching purposes at any level other than course participation directly affiliated with either Professional Learning Services or Catherine Collier.

Participants are required to print out and bring this handout to their scheduled course. All content will be addresses on the day of the program.

The Infection Control Exam Blueprint

10% Patient and Dental Healthcare Worker Education 20% Standard/Universal Precautions and the Prevention of Disease Transmission 10% Maintaining Aseptic Conditions 15% Instrument Processing 15% Aseptic Procedures 30% Occupational Safety

Agencies Involved:

The following agencies constitute who selects and enforces the regulations regarding Occupational Health and Safety for dental healthcare workers.

Occupational Health and Safety Administration - OSHA

OSHA compliance is mandatory for all healthcare institutions. OSHA is the law regulator and authority. Its main concerned with the health and safety of the employee

The Center for Disease Control – CDC is a federal agency that investigates, identifies, reports, tracks and tries to prevent and control diseases. The CDC is a nationally recognized agency regarding issues concerning public health, workplace hazards, infectious diseases, environmental health threats. It is a part of the Department of Health and Human Services. CDC establishes the guidelines and recommendations for infection control policies and procedures

Environmental Protection Agency - EPA is a federal agency that works to control and abate pollution in air, water, solid waste, pesticides, disinfectants, radiation and toxic substances. All surface disinfectants used in the healthcare industry should be approved by the EPA.

Food and Drug Administration – FDA is an agency of the Department of Health and Human Service that is responsible for ensuring the safety and effectiveness of food, drugs, cosmetics and medical devices.

National Institute for Occupational Safety and Health - NIOSH - It is the only institute responsible for conducting research and making recommendations for the prevention of work related disease and injury

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The owner of the dental practice is responsible to provide trainingTraining should be conducted:

Annually for all employees For new employees prior to initial assignment When a new product or new equipment is introduced into your practice

Office training can be conducted in various ways

Appoint a safety coordinator in your practice to train Hire a person who is extremely familiar with the guidelines of OSHA and CDC ETC. Attend a presentation or have an in office presentation and walk through assessment of equipment and supplies

Office Record Keeping For Employees

Employee medical or accident reports records are kept for full, part time or former employees A medical record is any record that holds the health status of an employee Record is completed by a doctor or healthcare provider Employees have the rights to access their record Employees are entitled to a copy of their medical records

Employee records also include, but are not limited to: CE credits – valid for 3 years Certification courses License Malpractice Insurance Any certification the employee carries Records of required immunization or decline Results of medical testing, medical opinions and treatment

All records are kept for a period of 30 years or the lifetime of the practice

Employers should inform outside services of office policies. Temps, interns or outside services are required to comply with all office policies regarding OSHA, Infection Control and HIPAA compliance Documentation and PoliciesDental Records should be: Legible to someone other than the writer Written in black or blue ink Do not skip lines, erase or white out info or changes All entries should be dated Sign all documents with full name and credentials Document patient acceptance and refuse of treatment Document any and all emergency situations that may occur for patient or employee Document treatment received or refusal of post exposure or accident for patients or employees

Remember.. If you don’t write it down .. You never did it

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How to handle an office inspection:

Ask inspector to present credentials The following process should occur with an inspector: Opening conference Walk through assessment of the facility – Office Investigation Closing conference reviewing the office findings Results of inspection / Practice owners have the right to appeals findings How to file for work related injuries

Occupational Exposure Control Plan - OSHA CFR 1910.1030

Employers are required by OSHA to have a written Exposure Control Plan. An Exposure Control Plan (EPA) protects workers from exposures to blood and other body fluids.

ECP reduces exposure incident costs and serves as a document to answer questions related to bloodborne pathogen

Exposure Control Plan should include the following information:

List the current names of high or low risk employees Must state their job classification and task descriptions Must state the methods of compliance Employees should receive training according to their job position and potential risk exposure Employee Tasks and Work Restrictions Employers should provide a comprehensive written policies manual regarding employees work

restrictions Work restrictions/exclusions are limitations in professional duties as determined by policies set within the

dental practice setting Restrictions/exclusions may be imposed on dental workers whose health status poses a high risk of

infection to patients, coworkers, or themselves Every dental practice should have a written work restriction and exclusion policy which includes who

may implement restrictions and exclusions

Work related injuries are considered accidents or injuries that occur in the workplace during the days and times employees are assigned to be there. They are injuries that require the employee to seek medical attention outside the office.

Employers must establish a log for each facilityOSHA Log 300 will assist the employer and employee with how to properly recognize and file a work related accident.

Log 300 - Classifies work-related injuries and illnessLog 301 - The complete injury and illness ReportLog 300A - This is a Summary Report that should be posted in the office from Feb.1st to April 30th.

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Hazard Communication Program - CFR 1910.1020

Occupational Safety and Health Administration (OSHA) guideline requiring dental offices to develop and implement a program to instruct all employees who might be exposed to hazardous materials in the safe handling and disposal of those materials.

These materials include but are not limited to: Amalgam Composites Glass Ionomers Disinfectants Bleach Phenols/ alcohols Impression materials Developer/ Fixer Injectable/ OTC

Safety Data Sheet (SDS) should contain the following information:

Information provided by manufacturers of potentially hazards related to the product Product identification Chemical content Hazardous ingredients Physical data, fire and explosion information Reactivity data Health hazard data Emergency and first aid procedures, spill or leak procedures Labeling and storage information.

The New Hazard Communication Standard was previously known as "Employee's Right to Know,”

Globally Harmonized System of Classification and Labeling (GHS). Allows employees to understand the risks associated with and protections needed when working with hazardous

chemicals or drugs. Required updates to chemical labels including the use of pictograms and signal words. Material Safety Data Sheets will be updated and be referred to as Safety Data Sheets.

The user of the chemical product assumes liability for any misuse of products

Follow manufacturer’sdirections for: Proper mixing Use/handling Storage and disposal Proper selection of personal protective equipment Effective ventilation First Aid protocol

Use of Secondary Container Labels Information

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Dental Unit Waterlines and Suction Lines

No more than 500 Colony Forming Units of bacteria /ml of water. Water lines can contain high amounts of rod- shaped, gram-negative bacteria known as Legionella pneumophilia. These bacteria are considered to be the cause of Legionnaires’ disease.

To minimize bacterial growth in the waterline purge the lines for 2 minutes at the beginning of the day, 30 seconds in between patients, and at the end of the day. In addition, use a tablet system for bottled water supplies or filtration system attached to in coming city water lines to control bacteria growth in water lines.

Bacterial growth in the dental unit waterline is encouraged due to: Size of tubing Surface material Speed of flow rate Intermittent flow rate

Available methods for treating the dental unit waterline:

Utilize Isolated Water Supply - Isolates the dental unit water from the municipal water supply. Water supply is filled and maintained by office staff

Utilize Chemical or Physical Treatments of the water supply Flushing the waterlines for 20-30 seconds clears the waterlines of free-floating microorganisms Utilize sterile water supply

Pros and Cons of having an isolated water supply

Isolate the dental unit from the municipal water supply Allow the practice to control the quality of water in the unit Provide a way to introduce chemical agents to waterlines and permit the use of water of known microbiologic

quality Cannot reliably improve the quality of dental unit water without additional chemical or mechanical treatment

against the biofilm Improperly maintained systems could deliver water of worse quality than from a municipal source.

Pros and Cons of Chemical treatment of waterline May be time-consuming and technique-sensitive Treatment involves purging the waterlines, adding a chemical to the water reservoir Require strict compliance with the recommended treatment regimen May be incompatible with dental equipment (the proper treatment protocol depends on the type and components

of the dental unit) Continuous-release chemicals may be incompatible with various dental materials (for example, dental

Adhesives)

Pros and Cons of utilizing physical treatments Produces water that meets or exceeds drinking water standards May include anti - retraction features Are not labor intensive when placing and replacing

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May require periodic chemical treatment of the post-filter segment of the waterlines to control biofilm May be expensive, as each waterline requires a separate filter that must be maintained daily or weekly,

depending on the brand Point of entry filters are a considerable investment and must be professionally installed

Pros and Cons of flushing the waterlines Helps to remove contaminants that may have been retracted during patient treatment Clears away free-floating organisms in the water, temporarily reducing the number of microbes in treatment

water

Flushing is not recommended as a control method for dental water quality Has only temporary effects (Biofilm bacteria continually break free and re-contaminate dental unit water during

the course of clinical treatment) When used alone, has little effect on waterline contamination Does not prevent or eliminate biofilm

Pros and Cons of utilizing sterile water delivery systemsAutoclavable, self-contained water systems with disposable or autoclavable tubing Bypass the dental unit's water line Deliver sterile water to the patient Used for oral surgery and implantology handpieces, ultrasonic scalers and retrofit devices for restorative

handpieces Have autoclavable components which require sterilization between uses

Suction unit lines should be cleaned in between patients and at the end of the day according to the product manufacturer.

Nitrous Oxide

Dental healthcare workers are exposed to N2O while administering the anesthetic gas to patients.

Implementing scavenging systems that vent unused and exhaled gas will keep N2O away from the work area.

Even with scavenging systems in place there is 12 times the NIOSH recommended limit in hospital operating rooms and 40 times the NIOSH recommended limit in dental operating rooms.

Properly operating scavenging systems have been shown to reduce N2O concentrations by more than 70%. CDC reports clearly demonstrate that simply using a system is not sufficient. The system should be continuously monitored and maintained to effectively reduce exposure to N2O.

Offices should monitor anesthetic equipment when installed and every 3 months thereafter

Monitor air in the worker's personal breathing zone and the environment (room air)

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Eliminate or replace:

Loose-fitting connections Loosely assembled or deformed slip joints and threaded connections Defective or worn seals, gaskets, breathing bags and hoses

Control waste N2O with a well-designed scavenging system that includes the following:

Securely fitting masks Sufficient flow rates (i.e., 45 liters per minute) for the exhaust system Properly vented vacuum pumps Room ventilation effectively removes waste N2O.

If concentrations of N2O are above 25 ppm, take the following steps:

Increase the airflow into the room Use supplemental local ventilation to capture N2O at the source Institute an education program that describes N2O hazards and defines prevention measures.

Symptoms of Nitrous Oxide exposure include difficulty breathing, headache, drowsiness

Radiation Exposure Controls Provide film badges Keep records of the test results Provide lead aprons, goggles, gloves as needed Dispose of lead aprons according to the EPA regulations

Radiation warning signs should be posted in facilities with x-ray units. The facility should survey the types of radiations used in the facility

Infection Control Practices and Policies

The goal of infection control is to break the chain of transmission and stop the spread of disease.

Infection Occurs when there is a place for an organism to live

Mode of Transmission - a way to transfer the organism to the host Causative agent - the presence of a dangerous organism Susceptible Host – Employee is susceptible Port of exit and port of entry

It is important to:

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Maintain host resistance Reduce or kill the number of organisms Stop the path of an organism before it enters a host Minimize or eliminate contact with blood and all body fluids Disease transmission occurs:

Indirect contact with blood or OPIW Indirect contact with contaminated objects When mucous membranes contact splatter Breathing airborne particles Parenteral Exposure

Bacteria and Viruses

Groups of Bacteria Include:Gram negative bacteria – stain pink or redGram Positive bacteria stain blue or purple

Shapes of Bacterial Include: Cocci- spherical cellsBacilli - Rod-shaped cellsSpiral - curved shaped cells

Endospores – one the most resistant dormant structures formed inside bacterial such as Geobacillus, Bacillius, and Clostridium. These bacteria are in biological spore test carpules

Factors which contribute to bacterial growth include:

Oxygen Obligated Aerobes – need oxygen to grow Obligated Anaerobes – cannot tolerate oxygen

Temperature – Thermophiles 132 degrees F –158 degrees F, Most resistant to heat is G. Stearothermophilus Mesophiles 71.6 degrees F – 133 degrees F Psychrophiles 33.8 degrees F- 71.6 degrees F

Acidity 0 = high acidity – 14 high alkaline Neutral is a pH of 7 - it is a balance between acid and base

Nutrients - bacteria need proteins, polysaccharides, lipids and nucleic acid such as RNA/DNA to grow

Source of Bacteria

Endogenous infections are caused by microorganism usually on the surface or inside the body Ex. Caries, periodontial disease,

Exogenous infections are caused by microorganisms that contaminate the body form an outside source Ex. HBV, Strep throat, measles, chickenpox

Bacterial and fungal infections include but are limited to:

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Rickettsia is caused by tiny parasites living in the GI tract of ticks and lice. These parasites are transmitted through insect bites. They are responsible for Typhus and Rocky Mountain Spotted Fever

Fungal Infections - Oral Candidiasis – Candida Albicans

Methicillin-Resistant Staphylococcus Aureus (MRSA) Staph Infections

MRSA staph infections are resistant of some antibiotics

This has evolved mostly because of the over use of antibiotics. 30% of people worldwide carry this infection mostare asymptomatic.

Prevention for MRSA Includes:Always maintain good hand hygieneNever squeeze or try to drain soresKeep wounds coveredDo not share personal items with others

Prions associated with Mad Cows Disease, and Creutzfeldt- Jacobs

Respiratory Disease

Influenza – “The Best Mutate”

Symptoms of Influenza including 2009 H1N1 influenza may have some or all of these symptoms:Fever - not alwaysCough Sore throat Runny or stuffy nose Body aches /Headache/ Chills Fatigue Sometimes diarrhea and vomiting

The flu can infected and re-infected Type A Usually present in larger epidemics Type B Accounts for most hospitalizations Type C Mostly respiratory Illness

Virus can drift and subdivide thus making immunity difficult

Elimination of potential exposure to influenza includes: Deferral of treatment Mask coughing individuals Identify patients with influenza-like illness at check-in Offer a facemask or tissues to symptomatic patients Follow respiratory hygiene/cough etiquette Reschedule non-urgent care – at least 24 hrs. wo/ fever or medications

Specific Recommendations for Dental Health Care

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Encourage seasonal influenza and 2009 H1N1 influenza vaccinations. Consistent implementation of sick-leave policies and vaccination Personal protective equipment (PPE) Self-assess daily for symptoms Stay home if ill or have family member that is ill Separate ill patients from others whenever possible if evaluating for urgent care. Patient-reminder calls to identify patients reporting influenza-like illness

Viral Infections:

Viruses are much smaller than bacteria, yet many viruses are fatal Viruses must have specificity for a particular cell – HIV CD4 cell Some Viruses establish a latency state in the host Treatment for most viruses address the symptoms… NOT the cause Transmitted by direct contact Ex: insects, blood transfusion Viruses are easily destroyed on external surfaces

Hepatitis A “The Salad Bar Disease”

Is from the spread of filth or unsanitary conditions it is an oral- fecal condition

Can be asymptomatic in a younger person. Can develop self-immunity to virus Self- limiting disease - 1% of patients require liver transplant Four inactivated vaccines are internationally available Vaccines are safe and effective, long-lasting Vaccines are NOT licensed for children less than one year of age.

Hepatitis B Is spread via percutaneously or permuscosally by infected body fluids It can be passed on through birth – If mother is HBsAG and HBeAg. There is a 70% change of the infant

contracting HBV Sexual activities Contact with contaminated needles or sharp objects

Hepatitis B Vaccine should be provided during professional training and offered to workers likely to contact blood or OPIWSerologic test not necessary prior to vaccine

Needle stick exposure for unvaccinated person should lead to initiation of HBVImmune Globulins are not a substitute for the vaccine

Hepatitis C “The Silent Epidemic” There is no vaccine for HCV The virus can live in body 20 to 30 years A small number of people with hepatitis C infection may develop liver cancer Liver failure may occurs as a result of severe damaged by hepatitis C Monitoring the Condition of The Liver

Who should be tested for HCV

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Illicit drug use Unexplained or unusual liver function tests Babies born to mothers with hepatitis C Health care and emergency workers who have been exposed to blood or accidental needle sticks Hemophiliacs who were treated with clotting factors before 1987 Long-term hemodialysis treatments Blood transfusions or organ transplants before 1992 Sexual partners of anyone diagnosed with hepatitis C infection Hepatitis D can’t replicate itself. It can only exist in the presence of Hepatitis B and is considered a coinfectionwith Hepatitis B

Hepatitis E is NOT transmitted via blood-borne route. It is transmitted via an oral-fecal route

Herpes Virus “The Houdini of Viruses”

Common properties include:DNA codingSimilar architectural structuresCan remain dormant for the life of the host

Most Common Strains of Herpetic Viruses

1. Herpes labilias - Human herpes virus 1 (HHV1) (HSV1)2. Genital herpes - Human herpes virus 2 (HHV2) is also called herpes simplex virus 2 (HSV2)3. Varicella-Zoster - Human herpes virus 3 (HHV3) causes chickenpox. Can cause a recurrent viral infection sucas herpes zoster or shingles4. Epstein-Barr Human herpes virus 4 (HHV4) Major cause of infectious mononucleosis5. Human herpes virus 6 (HHV) and 7 (HHV7)6. HHV6 and HHV7 are so common that most of humankind has been infected at some point7. HHV7 can also cause roseola8. Human herpes virus 8 (HHV8) - Discovered in Kaposi's Sarcoma , Associated with AIDS

HIV – Human Immunodeficiency Virus

Blood-borne viral disease resulting in a breakdown of the body’s immune system

HIV infects specific T-Cells which are responsible for immunity

When T-Cells die the body becomes weakened – immunocompromised

There is a very low risk .3% of acquiring HIV form a needle stick puncture

The Americans with Disability Act prohibits discrimination against patients with HIV

CDC Healthcare Vaccine Recommendation:

Measles, Mumps , and Rubella – MMR Varicella – Chickenpox Tetanus, Diphtheria and Pertussis –Tdap All dental Healthcare workers receive a baseline tuberculosis screening upon hiring regardless of the risk

classification of the facility

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Flu vaccine is offered to increase prevention

Always Report reactions to the vaccinationsMild reactions such as soreness, headaches, and fever are common side effects of the flu vaccineSevere reaction such as difficulty breathing, hives, or facial swelling, seek medical attention immediately.

Sharps Safety Includes: Organize a product selection and evaluation team Collect information from a dental “Safety Syringe and Needle Screening” form Set priorities for product consideration Safe handling of the device should be demonstrated by all employees that are required to use it Needles and syringes are single patient use only Rubber septum should be disinfected with alcohol prior to piercing Prepare the patient and organize the work area with prevention in mind. Keep exposed sharps in view and under your control. Visually inspect for unprotected sharps in trays and waste receptacles. Be responsible for the sharps you use. Activate safety features. Dispose in sharps containers. Use appropriate gloves for breakdown and disposal of sharp items and needles. Place contaminated items in an

appropriate leak-proof biohazards container.

Utilize Bio-Hazard Stickers on the following items:

On bags/containers of contaminated laundry On bags/containers of regulated waste On refrigerators and freezers that are used to store blood or OPIM On bags/containers used to store, dispose of, transport, or ship blood or OPIM (e.g., specimen

containers) Sharps containers Blood soaked gauze containers When dried blood can flake off from a disposed item When there are bloody gloves and sharps disposed in the container

What to do when you suspect puncture: Remove glove immediately and fill it with water to check for penetration Rinse with cool water and cover REPORT IMMEDIATELY TO SUPERVISOR Use OSHA form 300 to record and report

Post Exposure Evaluation

Report all incidents and accidents immediately to supervisor Record all necessary data required for testing Employees must receive a medical evaluation and follow up Paper work must be completed and ready to go to evaluation facility Source testing / employee testing If needed post exposure treatment should begin within 2 hours of incident

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Procedures and Prevention of Disease Transmission

Hand Hygiene - Resident and Transient Bacteria

Resident skin flora consist of microorganism that colonize the skin and become permanent residentsCan never be totally removed, but their numbers can be reducedResident flora can cause infection they are less likely to than transientTransient Bacteria contaminate hands come from contact with contaminated surfaces They do not live long or colonize or live longTransient bacteria can contain disease producing microorganism

Proper Handwashing effectively removes transient bacteria and reduces resident bacteria.

Your skin serves as your biggest barrier of protection and is compromised if: Chapped, presence of dermatitis, abrasions or open wounds Hands are washed too frequently By exposure to hand care products and dental materials Soaps, lotions and gloves should be compatible

Effective Hand Hygiene Protocol:

When to wash hands with plain or antimicrobial soap:

Prior to putting on or after removing gloves Before surgery to remove soil prior to using an alcohol hand rub Before and after eating After using the restroom When hands are visibly dirty or contaminated, or when they are visibly soiled with blood or other body

fluids

Surgical handwashing = 2 minutes -includes arms Surgical hand scrub/soap antisepsis should be performed before surgical proceduresUse either antimicrobial soap, or a combination of non-antimicrobial soap and water followed by an alcohol-based surgical hand rub.

Surgical hand soaps should contain one of the following ingredients: Chlorhexidine, Iodine, Iodophors, PCMX. All are broad spectrum, persistent and fast acting.

Alcohol based hand rubs - 60%-95% ethanol or isopropanol alcohol. They should be considered in addition to surgical hand soaps. CDC recommends the use of alcohol based hand rubs if water-boil advisory is in effect. Hand rubs do not contain detergents. Use soap and water if hands are visibly soiled

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Selection of Personal Protective Equipment (PPE)

Personal Protective Equipment:

Should Fit properly Do not touch or adjust during procedure Be removed and disposed of if visibly soiled or torn Be worn in work related areas Be disposed of according to waste regulations

When wearing PPE also consider: Do not eat or drink Do not applying cosmetics Do not handle contact lenses

Gloves

Gloves do not replace hand washing They should fit properly to reduce cramping and possible injury Gloves are for single use only, reuse and washing is unacceptable

Various Reactions to glove materials include:

1. Irritant contact dermatitis is common among dental workers. Irritant contact dermatitis is caused by physical irritation of the skin. It presents as dry, itchy, irritated areas of skin around the area of contact with the offending agent.

2. Allergic contact dermatitis - Hypersensitivity IV - is a skin condition that can result from exposure to chemicals such as methacrylates, glutaraldehydes and rubber. This type of dermatitis often appears as a rash beginning several hours or even days after contact.

3. Latex Hypersensitivity I is a potentially life-threatening allergy to the proteins contained in natural rubber latex. Latex allergies are serious as they include a whole body reaction within minutes of exposure. Common reactions include runny nose; sneezing; itchy eyes; scratchy throat; hives; and itchy, burning skin sensations

This condition is referred to as anaphylactic shock

Prevention of Latex Hypersensitivity includes: Competent patient medical history/ food allergies Employees require testing to provide proof of latex allergy Use powder free, latex free or low allergen latex products Schedule patient in early part of the day

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Remember your skin is your biggest barrier. Any condition which compromises healthy skin serves as a port of entry and increases the risk of percutaneous exposure to blood and body fluids. In both cases, contact with patients should be limited.

Work restriction for employee with glove related reactions include:

Seek diagnoses for latex allergy and determine course of treatment. Implement strategies that will reduce the use and contact with latex in the dental setting.

Mask and Face Shields

When selecting a mask for dental procedures consider the following features:

1. Fluid Resistance2. Submicron Bacterial Filtration Efficiency. Bacterial filtration rate of 95% for a particle range of 3

µm to 5 µm in diameter3. Breathability4. Flame Spread5. Mask selection is by procedure type

Mask should fit firmly around nose and mouth, no side openings Always remove from elastic band or ear loops Mask should be worn when wearing a face shield

1. Gowns 50/50% cotton polyester or 60/40% fluid resistant

Long sleeves and high collar, use caution with scrubs Fluid resistant gowns release debris on contactCotton polyester materials absorb matters and require laundering services

Protective Eyewear - OSHA requires employers provide safety glasses. It is the responsibility of the practitioner to use vigilantly and safely. Clean eyewear according to manufacturer’s instructions

Hand pieces projectiles can cause irreversible damage. They rotate at speed of 180,000 to 500,000 times per minute, And can project particles at speeds up to 50 miles per hour.

Implement Work Practice and Engineering Controls

Work practice controls - Incorporates behaviors that serve to reduce injury or exposure

Single handed recapping Incorporate cheek retractors Immediate removal of burs at point of use Sharp containers at point of use

Engineering Controls - The use of devices that eliminate or isolate a hazard

Needle recapping device – REVIEW ANNUALLY

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Sharps container Ultrasonic cleaners / Instrument washer Instrument cassette Forceps

Preparing the operatory for patient care includes:

a. Review medical history and note any restrictions. Check for any current of infectious diseases or allergies. If necessary, postpone treatment because of a health issue

Pre-Procedural Mouth Rinses should contain antiseptic properties and have residual activity to reduce the number of microorganisms:

On the surface of oral tissue Released through aerosols, spatter or direct contact Introduced in the patient's bloodstream during invasive procedures Pre-procedural mouth rinses should be unit dosed and given to patients in a disposable cup Use a pre-procedural mouth rinse containing either Chlorhexidine gluconate, Essential oils, or

Povidone-iodine.

b. Clean and disinfect all clinical work surfaces in the operatory. Utilize barriers and surface disinfectants

DisinfectionThe process of killing pathogens by physical or chemical means; it does not destroy spores and resistant viruses.

Surface disinfectants should be EPA approved and meet the following standards:

Broad spectrum TB kill claim – HIV/HBV kill claim Time efficient Contact time vs. Kill time Easy and safe to use Shelf life vs. Use Life

c. Utilize single - use items as much as possible.

d. Keep housekeeping surfaces, such as floor and walls clean and sanitize

e. Dispose of routine waste in lined receptacles in operatories

f. Discard sharp related items into sharps container in operatory

Preparing instruments for sterilization

Transportation of InstrumentsTransport instruments to sterilization center in cassette, covered tray or instrument bin

Pre-cleaning

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Pre-cleaning instruments is a critical step in processing instruments for sterilization. Proper fitting utility gloves should be worn by employee when handling contaminated instruments. Instruments should be places in an ultrasonic unit or unit designed to remove bio-burden load on instrument prior to sterilization.

Use recommended ultrasonic solutions and test ultrasonic cleaner routinely to make sure it has the proper cavitation strength to remove blood and bio-burdens. Proper pre-cleaning of instruments includes: Pre - soak items immediately or clean Do not allow to remain unattended Dried blood and body fluids make cleaning difficult and increases the possibility of an exposure incidence

Wearing utility glove, lift the handles of the basket in the ultrasonic unit. Allow ultrasonic solution to drip back into the bid. Then rinse instrument, pat dry and prepare for packaging instruments

Packaging Instruments

Use FDA approved materials All packaging material should have an internal and external indicator Make sure cassettes are closed and instrument tips are not sticking out Cassettes must be properly wrapped Avoid placing heavy instruments in bags Avoid using closed containers or staples Close pouched at the designated fold location Avoid using paper/ plastic bags in dry heat sterilizer

Instrument Sterilization

Sterilization is a process that destroys all forms of microorganisms, including bacterial endospores.

Classification of Instruments for Sterilization:

Critical – penetrates the mucous membrane requires sterilization. Critical items have the greatest risk of transmitting infection

Semi-critical – touches the mucous membrane requires sterilization or a minimum of HLD

Non- critical - touches intact skin such as blood pressure cuff or x-ray head Requires HLD

Methods of Sterilization

1. Steam Sterilization gravity displaced, vacuum pump, positive steam flush for 20-30 minutes temperature of 121F - 250 degrees F. Steam sterilization spore test should kill Geobacillus Stearothermorphilus

2. Dry heat sterilization – is static air for 60 – 120 minutes at temperatures of 320 - 375degrees F Dry heat sterilization spore test should kill Bacillus atriophaeus

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3. Unsaturated Chemical Vapor sterilization Chemclave – 20 minutes at 270 degrees F – The active ingredient for chemical sterilization is formaldehyde 0.23%. Chemical vapor sterilization spore test should kill Geobacillus Stearothermorphilus

MONITORING STERILIZER

1. Mechanical - Record temp and pressure2. Chemical - Use internal and external indicators3. Biological - Spore testing

CDC recommends weekly spore testing. Also test when: Implant device is being sterilized When using a new packaging device or material After sterilizer has been repaired After sterilizer has been moved or relocated If test results indicate a failed cycle take the unit out of use until problem for failure has been determined. All packages should be stamped with the date of sterilization. Facilities with more than one sterilization unit should have a system in place for identification of the unit used

for sterilization.

Unloading and storage of instruments

Allow instruments to dry and cool completely in sterilizer Do not touch moist packages with bare hands Do not store wet packages in drawers or cabinets. Stored all instruments wrapped unless they are for immediate use Do not store near contaminated items Instruments in bags stay sterile indefinitely. Replace bag and sterilize if bag is torn.

Proper disposal of waste

Always check state and local regulations All waste receptacles must be lined General waste – PPE, slightly soiled cotton or gauze, barriers Blood and saliva – dispose in sanitary sewer Tissue – sanitary sewer Teeth – sharps if no amalgam, or disinfect and give to patient Operatory trash – regular waste

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