INFECTION CONTROLMANUAL

FOR THE PRIVATE PRACTICE SETTING

A Practical Workbook

2011

TABLE OF CONTENTS

Foreword ………………………………………………………………………………… 3

Infection Control Officer……………………………………………………………….…. 4

Immunization ………………………………………………………………….………….. 5

Patient Screening ………………………………………………………………………… 7

Hand hygiene .……………………………………………………………………….……. 10

Barrier Techniques ………………………………………………………………………. 12

Needle and Sharp Instrument Safety, Waste……………… ………… ……………. 20

Significant exposures and dealing with exposures…………………………………... 22

Staff Injury Incident Report …………………………………………………………….. 24

Sterilization and Disinfection …………………………………………………………… 26

Biological Indicator ……………………………………………………….……………... 29

Disinfection ……………………………………………………………….……………… 32.Operatory Asepsis ……………………………………………………………………….. 33

Waterline and Suction Maintenance …….……………………………………………. 34

Radiography Asepsis ……………………………………………………………..……. 36

Laboratory Asepsis ……………………………………………………………………… 38

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INFECTION CONTROL MANUAL FOR THE PRIVATE PRACTICE SETTING

“An infection control manual should clearly describe protocols and procedures”. I have developed this template workbook to assist your office in the development of such a clinical manual within guidelines to help develop or maintain the following:i. standardization of your office policies with respect to infection control as well as actual clinical procedures ii. to assist in training new staff,iii. to have information readily available for your staff and patients andiv. for your peace of mind

Please tailor this manual to your own office by eliminating those choices which are not used in your office and replace them with those that are, as well as updating material as it becomes updated by CDSBC and CDC. Unfortunately, the CDA now defers to Provincial Dental Associations and no longer provides guidance in the form of an IPC Manual.

Adherence to current infection control procedures can virtually eliminate the risk of transmission of blood-borne pathogens within the dental setting. A dentist must not refuse to treat a patient on the grounds of the patient’s infectious state. A dentist infected by a blood-borne pathogen who practices current infection control methods does not pose a significant risk of infecting patients. However, in accordance with the CDA’s Code of Ethics, the practitioner should inform the dental licensing authority when a serious injury, dependency, infection or any other condition has either immediately affected, or may affect over time, his or her ability to practice safely and competently. The odd style of including the older mandates from the CDA has been used to demonstrate historically where the guidelines have and also as a reminder that they are evolving. Please replace this material when it becomes too outdated to be useful. This material has been assembled for you in such a way that you have access to it quickly and conveniently. Should you have questions about this material or anything involving infection control practice in your office, please feel free to contact me.

Dr. Nita Mazurat D226M, 780 Bannatyne,

Winnipeg, Manitoba R3E OW2 1-204-789-3695 Fax: 789-3916 mazuratn@cc.umanitoba.ca

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INFECTION CONTROL MANUAL

Policy for this office: Manual will be updated every ___ months.

DATE______________________

NAME OF OFFICE_______________________________________________________

OFFICE ADDRESS_______________________________________________________

INFECTION CONTROL OFFICER__________________________________________

UPDATE

DATE______________________

NAME OF OFFICE_______________________________________________________

OFFICE ADDRESS_______________________________________________________

INFECTION CONTROL OFFICER__________________________________________

UPDATE

DATE______________________

NAME OF OFFICE_______________________________________________________

OFFICE ADDRESS_______________________________________________________

INFECTION CONTROL OFFICER__________________________________________

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I. IMMUNIZATIONCDA Guideline: Resolution 99.13. March 1999“Up-to-date immunization status must be maintained for dentists and staff with patient-related duties, including clinic staff, office staff and laboratory personnel. This includes: hepatitis B, measles, mumps, rubella, and influenza.”

Note that three others have also been included, DPT (diphtheria-tetanus toxoid), polio, and tuberculosis. These are traditionally provided to Canadians by their pediatricians and family physicians during childhood and adolescence. Due to the increase of tuberculosis, especially among some groups of Canadians, offices may also wish to include tuberculosis in their own list.

OFFICE POLICY REGARDING IMMUNIZATION:The following immunizations will be required by this office:� Hepatitis B � Influenza � DPT� MMR (measels, mumps, and rubella) � Poliomyelitis� Varicella � Tuberculosis

IMMUNIZATION SCHEDULE AND BOOSTER Hepatitis B Two doses IM 4 weeks apart, third

dose 5 months after second, titre must be >10IU/L

Measles* (MMR) Live virus vaccine. Two doses required at least month apart after first birthday.

Mumps* (MMR) Live virus vaccine. One dose SC. Booster now being encouraged for HCW.

Rubella* (MMR) Live virus vaccine. One dose required on or after first birthday, document additional

Varicella One dose required between first birthday.and 12 years of age

Influenza Inactivated whole-virus and split-virus vaccine. Annual vaccination with current vaccine.

Tetanus-diphtheria toxoid (DPT) Two doses IM 4 weeks apart, third dose 6-12 months after second dose, booster every 10 years

Poliomyelitis Enhanced-potency inactivated poliovirus vaccine (E-IPV) is preferred for primary vaccination of adults.Two doses SC 4-8 weeks apart, third dose 6-12 months after the second. If

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booster is indicated, either form (E-IPV or Oral) can be given.

Tuberculosis One dose BCG SC in infants. Chest x-ray should be undertaken following a suspected exposure to tuberculosis.

RECORD OF IMMUNIZATION

DATE_______________STAFF NAME___________________________________________________________DATE OF BIRTH________________________________________________________

VACCINE DATE GIVEN DATE NEXT DOSE DUE

SEROLOGY(TITRE)

Hepatitis B 10mIU/ml

MeaslesMumpsRubellaVaricellaInfluenzaDPTPOLIOTB

(REPEAT FOR EACH TEAM MEMBER INCLUDING CUSTODIAL STAFF)

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II. PATIENT SCREENINGCDA Guidelines: 99.14, March/99“The medical history of patients should be obtained at the initial examination and reviewed during recall visits. Medical histories, physical examinations and laboratory tests may not always reveal the presence of an infectious process. Questions regarding medications, recent and past illnesses or operations, weight loss, swollen lymph glands, and oral problems may produce significant responses. Dentists should be familiar with the oral manifestations of infectious diseases, especially those which may be transmitted by dental treatment. The following table lists a number of disease in which oral and general signs and symptoms should be known:

COMMUNICABLE DISEASESSyphilisGonorrheaDiphtheriaInfluenzaMeaselsMumpsCandidiasis

Herpes Simplex InfectionsInfectious MononucleosisCytomagalovirus InfectionChicken Pox - ShinglesHIV – AIDSHepatitis B, C, and D

Certain histories demand additional consideration. Patients who are medically compromised, especially if related to organ transplantation, chemotherapy or immunotherapy, are at a risk of acquiring infections from contaminated dental instruments or from the attending personnel if effective infection control procedures are not consistently followed.”

By the same token, screening should not be used to discriminate against an infected individual by denying dental treatment or applying special and unnecessary infection control precautions. “Dental treatment can and should be provided in the dental office to most patients with infectious diseases since their safe treatment simply requires following established communicable disease protocols and taking routine precautions to protect the dentist, the staff, and other patients who attend the office. It is recommended that patients in advanced stages of infectious diseases be managed in hospital based dental programs that are staffed and equipped to provide comprehensive dental care to medically compromised patients.” 99.16, March/99

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MEDICAL HISTORY FORMSMedical histories should include questions relating to infectious diseases which make reference to all of the following:

� Medications

� Recent and past illnesses

� Recent and past operations

� Currently being actively treated by a physician

� Weight loss

� Swollen lymph glands

� Oral problemsIn addition, although there are no CDA Guidelines for this, your office may wish to make policy regarding the active treatment of patients with herpetic lesions in order to eliminate the risk of herpetic whitlow and/or ocular infections from aerosolization of the herpetic virus.

Our office policy regarding treatment of patients with herpes simplex lesions:

Upon identification of a herpetic lesion, prodromal stage, the patient will be: � seen � not seen� appointment schedule will be modified to avoid treatment during the vesicular stage

Upon identification of a herpetic lesion, vesicular stage, the patient will be:� seen unconditionally � seen only for relief of pain� reappointed for active treatment� not seen

Upon identification of a herpetic lesion, crusting stage, the patient will be:� seen unconditionally � seen only for relief of pain� reappointed for active treatment� not seen

Upon identification of a herpetic lesion, immediate post-lesion stage, the patient will be:� seen unconditionally � seen only for relief of pain� reappointed for active treatment � not seen

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COPY OF OFFICE PATIENT MEDICAL HISTORY FORM

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III. HAND HYGIENESOAPS AND ANTISEPTIC AGENTSThe following has been taken directly from Health Canada’s Infection Control Guidelines. Your office needs to choose a soap or antiseptic agent that meets your criteria.

“The purpose of hand washing is to remove soil, organic material and transient microorganisms from the skin. Few clinical studies have defined the absolute indications for hand washing with plain soaps (detergents) versus hand antisepsis with antimicrobial products. Controlled trials have not documented decreased infection with the use of antiseptic agent over plain soap for routine hand washing in the general health care setting The degree of reduction in microbial numbers on the hands of health care providers necessary to protect the recipient of care has not been defined. Antiseptic agents may be preferable for the care of patients if there is a possibility of antimicrobial-resistant organisms, such as intensive care units. Understanding the distinctive ingredients and uses of the soap and antiseptic products available is important in choosing the appropriate agent for the appropriate situation. If an antiseptic product is used, it should be selected for its chemical composition, its type and spectrum of activity, its onset and duration of activity, the application for which it will be used, its cost, allergenic potential and acceptability to the users. Whatever product is used, it should be applied at the right dilution for the recommended time with standard methods of application. Antiseptic hand cleansers are designed to rapidly wash off the majority of the transient flora by their mechanical detergent effect and to exert an additional sustained antimicrobial activity on the resident hand flora. Several studies have demonstrated superior efficacy of waterless hand scrubs compared with hand washing with soap and water or chlorhexidine. A major disadvantage of these scrubs is that they can not be used if the hands are soiled. The routine use of triclosan is not recommended due to lack of evidence for superior efficacy and evidence of product being introduced to the food chain.

PROCEDURE FOR BEGINNING AND END OF EACH CLINIC SESSION 1. Do not wear fingernail polish, fake fingernails, or long fingernails because of risk of

harboring increased numbers of microorganisms.2. Remove jewelry including watch unless it can be maintained under cuff of uniform

and gloves.3. Wet hands and fingernail brush with cool water. Place soap on brush and clean

fingernails for 15 seconds or until visible soil is removed. Alternately, use an orangewood stick to clean the fingernails.

4. Rinse under cool, running water.5. Place more soap on the hands and vigorously scrub hands directing particular

attention to thumb and fingertip areas for a minimum of 15 seconds. Rinse under cool, running water.

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6. Dry hands with single use, disposable towels. Faucets which are not foot, elbow or knee operated should be turned off a towel being careful not to recontaminate the hands.

Protocol for wash before and after gloving

1. Wet hands with cool water.2. Scrub vigorously for a minimum of 15 seconds3. Rinse.4. Dry hands using single use, disposable towels.

The brand name of hand washing soap used in our practice is: ______________________

It contains: � 4% chlorhexidine� PCMX (parachlorometaxylenol)� iodophor solution� other – name

Hand creams or barriers to reduce dryness should not be petroleum based if latex gloves are used as this causes deterioration of gloves. This in turn will leave the user more at risk due to breaks in the gloves.

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IV. BARRIER TECHNIQUESA. Personal Protective Equipment (PPE): Gloves, Masks, Glasses, Uniforms

1. GLOVESCDA Guidelines: Resolution 99.13, March/99

“Gloves should be worn when contact with blood, saliva and body fluid is anticipated, and changed between patients.”

Resolution 99.16, March/99 “ Gloves should not be worn indiscriminately. They are not to be used when greeting patients, handling records or radiographs, but only when performing intraoral procedures or handling instruments to be used or used within and around the oral cavity. Gloves are disposable items and similar to injection needles, anesthetic carpules, and saliva ejectors, must be discarded after use on each patient”

“If latex allergies are present, precautions must be taken to avoid contact with latex allergens.”

“Gloved hands should never be washed. Soap solutions degrade the glove material and may violate the integrity of the barrier. A fresh but appropriate pair of gloves must be used for each patient.”

“Heavy duty utility gloves should be used for handling contaminated instruments during cleaning.”

2. Masks:“Masks should be worn to protect oral and nasal mucosa from spatter of blood, saliva and particulate matter.”

“Medical grade barrier masks covering the mouth and nose should be worn during any dental procedure where splatter or aerosol spray is anticipated (less than 6µ). For most dental procedures, filtration efficiency of 95% for particles 3 to 5 microns in diameter is considered sufficient. The wearing of masks may also be appropriate whenever dealing with patients who are immunologically compromised, if the dental staff member has an upper respiratory tract infection, and during instrument cleaning prior to sterilization.”

“While it is not suggested that a fresh mask be worn for each patient, all masks lose their effectiveness upon becoming moist, which, depending upon the nature of treatment, may occur within one to two hours. Masks should be changed at least following a procedure where spatter or aerosol spray was created.”

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3. Protective Eyewear“Eyes of dental personnel and patients should be protected with some type of covering to protect from spatter of blood, saliva and particulate matter.”

“It is recommended that the eyes of all treating staff be appropriately protected. This is partially accomplished by standard prescription glasses or glasses with plain lenses; however, the effect of this barrier is dramatically increased when protective side pieces are used. Glasses will become contaminated and should be washed in conjunction with hands using running water and an antimicrobial soap solution. Clear face shields may also be used in place of protective eyeglasses, however, a mask should still be worn to protect the mucosa of the mouth and nose. Protective eyeglasses for patients should also be used whenever splatter or aerosol spray is anticipated. These may be disposable or be capable of being subjected to chemical disinfection.”

4. Clothing “A high temperature wash cycle (60° - 70° C), with normal bleach concentration, followed by machine drying (100°C) is recommended for clothing. Dry cleaning and steam pressing is also appropriate.”

“When outerwear does not include use of long sleeves and high collars, replaced by short sleeved clothing washing of the forearms will be necessary. In either case, a change into street clothes will be necessary at the end of the day. Gowns or other protective clothing should be changed and appropriately washed whenever they become visibly soiled, no less often than on a daily basis.

PERSONAL PROTECTIVE EQUIPMENT – our office policies

1. GLOVES

A. Treatment gloves Treatment gloves are to be worn: � treating all patients when contact with blood, saliva, and body fluid is anticipated� performing intra-oral procedures� handling instruments to be used or used within and around the oral cavity

Treatment gloves are not to be worn when:� greeting patients� handling charts or radiographs

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TREATMENT GLOVESDATE BRAND COST DISTRIBUTOR COMMENTS

B. Sterile Surgical Gloves

DATE BRAND COST DISTRIBUTOR COMMENTS

C. Overgloves

� Overgloves are used � Overgloves are not used Overgloves will be worn when:� accessing additional instruments or supplies � handling records (charts and additions to charts) and radiographs� other:

DATE BRAND COST DISTRIBUTOR COMMENTS

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D. Utility gloves

Χ Heavy, puncture-resistant nitrile gloves are used � Yes � No

∆ � Operatory surface disinfection and instrument cleaning.

Ε � Utility gloves are rebagged and resterilized following each patient.

Φ � Other: (describe techniques)

DATE BRAND COST DISTRIBUTOR COMMENTS

2. MASKS Masks are to be changed in our office:� Every patient treatment where high speed instrumentation is used.� Every one or two hours or whenever the mask becomes moist.� Other:

Masks are to be removed when:� Leaving the operatory to speak on the telephone� Speaking to a patient and not anticipating treatment resulting in aerosol production� Other: describe:

Once masks are removed they are:� Discarded at the operatory� Other (describe)

DATE BRAND COST DISTRIBUTOR COMMENTS

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3. EYE PROTECTION

In our practice staff eye protection: � Requires side shields � Does not require side shields

Eye protection is worn:� During active patient care� While performing equipment and instrument cleaning procedures� While performing all laboratory procedures

Once contaminated, staff eye protection is:� Washed in antimicrobial soap solution and running water� Other

EYEWEAR FOR STAFF WORN IN OUR OFFICEDATE BRAND COST DISTRIBUTOR COMMENT

In our practice patient eye protection is:� Available for patients � Not available for patients

� Requires side shields � Does not require side shields

Once contaminated, patient eye protection is:� Disposed of � Washed in antimicrobial soap solution and running water� Disinfected

EYEWEAR FOR PATIENTSDATE BRAND COST DISTRIBUTOR COMMENTS

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4. PROTECTIVE OUTER WEARIn our office, uniforms: � may be worn to work� staff wears street clothes and then changes for active patient care� uniforms may be worn to work if the uniform is covered with a lab coat or clinic jacket with high collar, and long, tight cuffed sleeves� lab coats or clinic jackets are removed for breaks and meals or leaving the office� other (STATE)

When protective outer wear is removed state where it is left:

PERSONAL PROTECTIVE EQUIPMENT (1 for each staff member)Provide check (√) for that which applies to each member of the dental team.

STAFF NAME____________________________________________________

TEAM MEMBER � Dentist � Dental hygienist � Dental assistant � Reception

ALLERGIES: Latex � YES � NOOthers: List __________________________________________

GLOVES Size: � Extra small � Small � Medium � Large � Extra large

Type: � Latex: Brand __________________________ � Vinyl: Brand __________________________ � Nitrile: Brand _________________________

� Other _______________________________

FACE MASKSType: � Cone: Brand_________________________

� Ear loop: Brand ______________________� Procedural: Brand ____________________

EYE WEARType: � Non- prescription protective � Prescription protective � Prescription/ Loupes

UNIFORMType: � Scrubs � Lab coat � Clinic Jacket � DisposableUniform allowance provided: � YES � NO

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B. Equipment BarriersCDA Guideline: Resolution 99.13- “Counter tops, working surfaces and operatory furniture, especially if aerosols and/or

blood splatter will be generated, should be protected by disposable covers and/or disinfected by a suitable liquid.”

CDA Guideline: Resolution 99.16- “Operatory hygiene is practiced to reduce the microbial contamination of high risk

sites, such as: counter tops, drawer pulls, bracket tables, light handles and switches, chairs, floors, and walls. Operatory hygiene ought to be performed after each patient, and is accomplished by either barrier protection or surface disinfection.”

EQUIPMENT BARRIERS – our office policies

Disinfection follows the use of barriers always: � Yes � NoDisinfection follows the use of barriers only when: (state when)

EQUIPMENT BARRIERS USED

SITE TYPE EXCEPTIONSHEADRESTCHAIR: controls bodyLIGHT HANDLESLIGHT SWITCHRADIOGRAPHIC HEADRADIOGRAPHIC CONTROLDRAWER HANDLES: list areas:

AIR/WATER SYRINGESUCTION : high volume saliva ejectorCOUNTER TOPSBRACKET TABLESTOOLS: assistant operatorHAND PIECE HOSESAMALGAMATORCURING LIGHT

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C. Other Protective ConsiderationsCDA Guideline: Resolution 99.13- “Rubber dam should be used in restorative dentistry wherever possible.”CDA Guideline: Resolution 99.16- “The dam, by isolating an area of the mouth, protects dental personnel from

exposure to blood, saliva and oral aspirations, all of which may harbour pathogenic organisms.”

- “In this regard, two other practice techniques reduce the number of micro-organisms and hence reduce the risk of disease transmission. The first is the use of an antiseptic or antimicrobial mouthwash by the patient for 30 seconds prior to any intraoral procedure. The mouthwash will reduce temporarily the number of viable oral organisms. The second is to use high volume suction, which is an effective method of removing the blood and saliva splatter and aerosol spray created by high-speed and ultrasonic instruments.”

USE OF RUBBER DAM� Used routinelyState brand used _____________________________

� Not used except for the following:

PATIENT RINSING� Patients are not required to rinse � Patients are required to rinse � water only � antimicrobial rinse� Prior to high speed instrumentation only.� Prior to any intra-oral procedure.

HIGH VOLUME EVACUATION� Used routinely� Used only when:

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V. NEEDLE & SHARP INSTRUMENT SAFETY AND WASTE DISPOSAL

CDA Guideline: Resolution 99.13, March/99- “Sharp items, such as needles and scalpel blades, should be placed in puncture-

resistant containers prior to disposal and discarded according to provincial and municipal requirements.”

CDA Guideline: Resolution 99.16, March/99- “All used sharps should be placed in sturdy containers, which are identified as

containing sharps. It is safer if the container is not completely filled and if it is secured by a tight fitting lid. Used sharps, no matter how they are packaged, cannot typically be disposed of in the general waste. Dental personnel should comply with pertinent municipal or provincial laws regarding the disposal of sharps originating from the private dental office.”

CDA Guideline: Resolution 99.16, March/99“Disposable materials should be discarded appropriately. Many of the wastes generated by the dental office are general waste and should be disposed of according to applicable federal, provincial, and municipal regulations. There are no clearly specific regulations concerning the handling or disposal of infectious waste products produced in the private dental office. Accordingly, it is suggested that such disposable wastes be carefully bagged by staff wearing appropriate personal protection, and disposed of according to any applicable municipal, provincial or federal regulations.”

A. NEEDLE & SHARP INSTRUMENT SAFETY AND DISPOSALAll clinical items which could cause a cut or injury are included. These sharps must be disposed of in a puncture-resistant, biohazard-labeled container with a closed lid.

NEEDLES: Between injections and before needles are removed from non-disposable syringes, needles should be recapped with either a one-handed scoop technique or a mechanical device designed to hold the needle sheath. Used needles should not be bent or broken prior to disposal.

OFFICE POLICY REGARDING DISPOSAL OF SHARPS

SHARPS LIST IN OUR OFFICE: √ appropriate boxes and add to list� needles (injection, etch, suture) � broken orthodontic appliances� endo instruments � waste wire (surgical, ortho, prostho)� burs � broken glass

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� scalpel blades (surgical and prosthetic) � otherDISPOSALDate: _________________________Puncture-resistant, biohazard-labeled, closed container(s) purchased:From: _________________________________________________________________Telephone: _____________________ Fax:____________________________________Cost: __________________Special instructions: _____________________________________________________

B. CONTAMINATED WASTEItems which have had contact with blood or other body secretions are considered contaminated waste, also known as “biohazard” or “infectious waste” if it is capable of causing an infectious disease. Although there are no regulations in Canada regarding the disposal of this waste, the individual dental office may make distinction regarding the handling of blood soaked disposables and extracted teeth. These items can be sterilized in an autoclave in bags specific for this purpose prior to being discarded in general waste.

Office policy regarding contaminated wasteBlood soaked wastes are gathered and sterilized � Yes � No

Hazardous waste containers:Name:________________________________________________________________

Company purchased from ___________________________________________________

Cost ____________________________________________________________________

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C. EXPOSURES “Significant exposures to blood and/or body fluids, including percutaneous injuries (needle sticks, lacerations) and splashes onto non-intact skin and exposed mucous membranes, are a serious concern and should be treated as a medical emergency.”

Prevention of occupational exposures to blood/body fluids is an important goal. Ways to prevent injury in the dental office:Use of engineering controls

Engineering controls in our office include: (name them)

Use of work practice controls established to avoid handling, using, assembling or cleaning contaminated sharp instruments, equipment or appliances, and the use of sharps containers.

Use of work practice controls used in our office include:� Sharps are not passed to the operator� Burs are removed prior to removal of the handpiece from the operatory for sterilization� Fingers are not used for retraction/palpation during suturing and administration of anesthesia� Identifying and removing all sharps from an instrument tray prior to instrument cleaning� Used sharps are placed in appropriate puncture-resistant containers located as close as feasible to where the items were used� Needles should be recapped as soon as possible after use, and before removing the needles from the syringe for disposal� One needle may be used for multiple injections on the same patient, however, the needle should be recapped between each use

Action if injury occurs to staff member:

1. Remove gloves or immediate clothing to assess the extent of injury2. First aid should be administered, if necessary, for percutaneous exposures.3. Immediately wash the area, including the puncture or wound using soap and water. The application of caustic agents such as bleach, or the injection of antiseptic agents into the wound is not advisable.4. Report the injury to the Office IPC Officer who should contact the appropriate healthcare professional for advice and possible referral, and begin the necessary documentation. 5. Documentation should include:

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- Name of the exposed DHCP and note details of the Immunization Record- Date and time of the exposure.- Nature of the exposure, including the dental procedure being performed, the extent of the exposure, and immediate action taken.- The name and health status of the source person,including details regarding any infectious diseases known or suspected- Follow-up counseling and post-exposure management

The source should be asked to submit to blood testing and both exposed transported to an appropriate facility where PEP will be provided within 2 hours after the injury if needed.

When an exposure has occurred during active patient care, remember that the source may be a patient who still requires active care such as suturing or a provisional restoration. Any instruments, devices, or other patient care items that have been contaminated by the blood of the exposed will need to be replaced or decontaminated to provide care.

Name of facility which will be used for testing

________________________________________

Phone number

______________________________________________________

CDA Infection Prevention and Control in the Dental Office

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NOTE: Confidentiality of this form MUST be ensured, ie only those people who need to see this form may do so

Name of Exposed Person: ______________________________________________________

Hepatitis B vaccination completed: date__/___/__ Post vaccination titre: ___mIU/ML

Date and time of Exposure: _______________________________________________________

Procedure being performed: _______________________________________________________

Where and how exposure occurred: __________________________________________

Did exposure involve a sharp device: � Yes � No

Type and brand of device: ____________________________________________

How and when during handling exposure occurred: _______________________

Extent of the exposure (describe): __________________________________________________

� Blood � Saliva � Other body fluid Describe______________________________

Percutaneous injury:

Depth of wound:______________________

Gauge of needle:______________________

Was fluid injected: � Yes � No

Skin or mucous membrane exposure:

Estimate volume of fluid:________________

Duration of conact:_____________________

Condition of skin: � Intact � Chapped � Abraded

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Source Person Information:_______________________________________________________

Known infectious disease:__________________________________________________Follow-up Care (describe in detail)

Date Caregiver Action Taken

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VI. STERILIZATION AND DISINFECTIONCDA Guidelines: Resolution 99.13, March, l999

“Appropriate sterilization methods should be used on all dental instruments.”Single use objects must be discarded following use.

Heat sterilizers should be biologically monitored as to their effectiveness and a record of this monitoring maintained.

Counter tops, working surfaces and operatory furniture, especially if aerosols and/or blood spatter will be generated, should be protected by disposable covers and disinfected following use.

1. STERILIZATIONOffice policy for containment of contaminated instruments

Instruments transported from operatory to containment area to prevent air-borne contamination State how transported:

Office policy for decontamination of contaminated instrumentsPPE to be worn during decontamination step:� Mask � Eye wear � Utility gloves � Protective clinic garment

Instruments rinsed in cool water before further cleaning� Yes � No

Ultrasonic cleaner used� Yes � No

Instructions for use:Solution used _________________________________

Solution changed:� at end of each workday� other: state when

State how ultrasonic is to be cleaned:

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ULTRASONIC TESTINGFunctioning of an ultrasonic unit should be done using the aluminum foil test.Cut a piece of lightweight aluminum foil about one inch shorter than the length of the chamber and one inch longer than the depth of the solution in the chamber. Insert the foil vertically into the filled chamber with the length of the foil running the length of the chamber and the bottom of the foil about one inch above the bottom. Do not let the foil touch the bottom of the tank. Operate the unit for 20 seconds. Remove the foil and observe for small indentations (pebbling) on the foil. This pebbling should be fairly evenly distributed over the entire foil. If there are areas greater than one half inch square having no pebbling, the unit may need servicing. This should be done monthly or anytime it is observed that organic material is being left on instruments.

DATE STAFF MEMBER RESULTS ACTION TAKEN

Other cleaning method: a. Manual � Yes � No

Name of Detergent used________________________________________

b. Instrument washers – washer/disinfector Washer brand Purchase date Cost Chemicals

used/Purchased from

Cost of chemicals

Instructions for use:

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OFFICE POLICY FOR STERILIZATIONInstruments are inspected before packaging for sterilization.

Instruments are dried with _______________________ before packaging.

Hinged instruments are opened before sterilization� Yes � No

Lubricant used for hinged instruments before each sterilization� Yes � No

Packaging used for Critical instruments� Paper envelopes � Paper/plastic envelopes� Double thickness cloth � Nylon/tape sealed� Plastic/tape sealed � Plasticized/tape sealed� Heat sealed packages � Dennison wrap� Other

Packaging used for Semi-critical instruments� Paper envelopes � Paper/plastic envelopes� Double thickness cloth � Nylon/tape sealed� Plastic/tape sealed � Plasticized/tape sealed� Heat sealed packages � Dennison wrap� Other

The sterile shelf life is dependent on the type of packaging material:Packaging material Shelf lifePaper or paper/plastic envelope 1 monthDouble thickness cloth 2 monthsNylon, plastic, plasticized and tape sealed 6 monthsHeat sealed packages 12 months

Labeling of sterile packages � Yes � No� Date� Sterilizer serial number� Cycle number or time � Contents

Indicators/integrators used � Yes � No� Class 1� Class 3� Class 4� Class 5

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STERILIZER TECHNIQUE DATE

PURCHASEDSERIAL NUMBER SERVICED

Steam

Dry Heat oven

Other

Instruction Manuals are kept:� In this manual� Other location:________________________________________________________

USE OF BIOLOGIC INDICATORS (BI)/SPORE TESTING

Biologic monitors or indicators (BI) monitor that the heat sterilization equipment is working optimally. Biologic monitors are spore tests.

All sterilizers must be monitored according to Provincial Dental Association standards. When using an ethylene oxide gas sterilizer, each load should be monitored with a spore test. In all cases, the user must ensure compatibility of the spore test and the sterilization process being monitored.

Steamvapour Geobacillus stearothermophilusDry heat Bacillus atrophaeusEthylene oxide Bacillus atrophaeus

In our office Biological indicator testing is performed:

� Daily� Once per week� Whenever a new type of packaging material or tray is used� During and after training of new sterilization staff� During initial use of a new sterilizer� First cycle after a sterilizer has been repaired� After any change in sterilizer-loading procedure� Three times after new packaging, new sterilizer, following repair� With every implantable device and hold device until results of test are known

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TECHNIQUE:1. Place test strip in the middle of several instrument packages or inside a wrapped package.

2. Information needed on the package:•sterilizer serial number •date of submission to lab •date of sterilization test • time and temperature conditions •operator

INCUBATOR DATE PURCHASED

SPORE TESTS PURCHASE:DATE MANUFACTURER DENTAL SUPPLIER COST

SPORE TESTS ARE SENT TO:DATE COMPANY ADDRESS (COST)

RECORD OF BIOLOGIC MONITORING (maintain records for each sterilizer for a period of ____years)

NAME OR SERIAL NUMBER OF UNIT __________________________________

DATE RESULT WHERE SENT DATE RESULT WHERE SENT DATE RESULT

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STORAGE OF CRITICAL INSTRUMENTS FOLLOWING STERILIZATION

� Remain in sterilization area � Placed in operatory____________________________ ___________________________________________________________________ _______________________________________� Trays � Do not use trays

Instruments for tray set –ups in our office:

RESTORATIVE ENDODONTICS PERIODONTICS

SURGICAL PERIO REMOVABLE PROSTH FIXED PROSTH

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2. DISINFECTIONCDA Guideline:

“Counter tops, working surfaces and operatory furniture, especially if aerosols and/or blood spatter will be generated, should be protected by disposable covers and/or disinfected by a suitable chemical disinfectant .”

Our office policy for disinfection:GENERAL RULES: Operatory treatment areas are prepared by thorough cleaning of surfaces, followed by disinfection with an effective agent and placement of barriers. All surfaces and items touched by and contaminated by saliva or blood initially are cleaned by scrubbing vigorously – the sanitization step – and then disinfected by a second scrub.

When working with disinfectants PPE used: � Mask � Eyewear � Utility gloves � Protective clothing

Method of use for operatory asepsis:� Wipe/wipe� Other

Material used for clinical contact surfaces:� J cloth � 4 x 4 gauze sponges � Paper towel � Other

A. OPERATORY PREPARATION

1. List of procedures for our office operatory preparation

Perform hand hygiene Place PPEWipe following surfaces: � bracket table � counter tops � light handle and switch � chair � stools � suction valves and hoses � list others:

� Run water lines dedicated system __ � Run water lines closed system ____ minutes

State your office procedures for operatory preparation first of day

:

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List of procedures for our operatory following each patient care:Suggested includes the following:� Place utility gloves� Flush lines – high speed, air/water syringe –20 seconds, remove handpiece and air/water syringe� Flush clean water through suction 20 seconds� Gather all instruments, transport to decontamination area � If placing instruments into holding solution, ultrasonic cleaner, or washer/disinfector immediately then protect handles of these three methods from cross-contamination by wearing clean treatment gloves under utility gloves and removing utility glove from hand which will be used to do so. Place instruments into cleaner with hand covered with utility glove. � Return to operatory, remove barriers� Sanitize� Disinfect

List of procedures for our office operatory following routine patient care:

High level Disinfectant(s) – High level immersion disinfectants are used for items that cannot be heat sterilized such as shade guides, rubber bowls, glass slabs

Office policy regarding high level disinfection: items disinfected using high level disinfection: (state items)

Name of disinfectant Manufacturer

Shelf life Use life Reuse life Testing

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B. Waterline and Suction MaintenanceCDA Guideline for Waterlines: Resolution 97:72, September, l997

Avoid heating water for the dental unit.

At the beginning of each clinic day, purge water lines by flushing thoroughly with water.

Run high speed handpieces for 20-30 seconds after each patient to purge all air and water.

Use sterile water or sterile saline when flushing open vascular sites and/or cutting bone during invasive surgical procedures.

Follow manufacturer’s instructions for daily and weekly maintenance if using bottled water or other special delivery system.

OUR OFFICE POLICIES REGARDING WATERLINES

Water is tested routinely: � Yes � NoTested for what organisms: (If other than Heterotrophic plate count)_______________Results kept: � in this manual � in separate manual

Location: � operatory sinks � high speed � air/water � ultrasonic scalerLines are purged: � at the beginning of the day � after each patientLength of purge:_________

Instructions for system included in this manual: � Yes � No

At the end of the day:� water is emptied and air/water syringe used to remove remaining water from lines� other

WATER TESTINGDATEINSTALLED

MANUFACTURER INSTRUCTIONS

DATE TESTED LAB USED FOR TESTING

COST OF TESTING

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WATER SHOCKINGUNITDATE SHOCKED

MATERIAL USED TEST RESULTSDATE

COST OF TEST AND MATERIAL

SUCTION MAINTENANCE:Suction lines to be flushed: � After each patient � At the end of each day� Other (state)How flushed: � Water only � Oral evacuation system cleaner: Name____________________________________________Instructions:____________________________________________________________________� Other (state)

Suction Valves to be cleaned: � internally with brush after each patient� at end of day� replaced after each patient and sterilized� other (state):

Unit suction to be cleaned: � After each patient� At the end of each day� Other (state):

Person responsible for cleaning unit suction _______________________________________________

Additional instructions for cleaning: ________________________________________________

Suction canister to be cleaned: � Daily� Weekly� Other (state)

Person responsible for cleaning:______________________________________________

Additional instructions for cleaning:

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VII. RADIOGRAPHY ASEPSISThe same guidelines for all operatory asepsis guide infection control during radiography. It helps if it is broken down into four phases:

1. placement and removal of lead apron2. film placement and exposure3. transport of film to developer4. development of film

1. Placement and removal of lead apron.Handle lead aprons and thyroid collars with clean hands or overgloves. Disinfect lead aprons when placed over contaminated patient bibs.

2. Film placement and exposurePlace barriers on switches that cannot be exposed to disinfectant.Either place barriers on the tube head or treat as per usual surface disinfection at the end of patient treatment. Film placement (eg. RINN ) equipment will be sterilized

3/4. Transport of film to developer and developing.This depends on work space available, developer, and barrier characteristic of the film packet. Work space – none at developing areaDeveloper – dark room or daylight loaderFilm – Barrier enclosed or analogue plain

Space in developer area

Daylight loader Dark room

Non-barrier covered film

Inadequate – disinfect packets in operatory using usual disinfection techniques including use of utility gloves and manufacturer’s recommended time for disinfectionTransport uneventful Adequate-transport in a covered paper cupDisinfect at developer area

If disinfected:Proceed with bare hands, transport uneventfully

If contaminated:Transport in covered paper cup with clean hands.1. Place barrier inside loader, place cup on it. Also place second cup, clean gloves and close top.2. Place clean hands into loader and don gloves.3.Packets are

If disinfected Proceed with bare hands, transport uneventfully.

If contaminated:Transport in covered paper cup with clean hands.Disinfect as described for operatory. Process with bare hands or with clean treatment gloves or with overgloves.

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opened and films drop on clean surface.4.Remove gloves, place into 2nd cup and develop as usual. 5.Trash is removed after films drop.6. Hands are washed

Barrier covered analogue film

Inadequate – open into clean cup in operatory. Transport with clean hands and process.

Once barrier removed, transport and process uneventful.

As with daylight loader.

Adequate – as above or transport to area in covered cup, open onto clean surface and process

Transport with care.Process uneventfully once barrier removed and film placed on clean surface, process uneventful.

As with daylight loader.

Barrier covered digital

Open into clean cup prior to leaving area, remove gloves, wash hands, place into scanner

Sensors Replace barriers and disinfect between patients

Infection control for radiography in our office:

Transport to developing area: Describe:

DIGITAL RADIOGRAPHY:

Disinfectant used for sensors:

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VII. LABORATORY ASEPSISCDA Guidelines: The principles of infection control and general cleanliness are applicable to the laboratory environment.

Basic Principles:1. All items entering and leaving clinics and laboratories will be disinfected.2. Items are placed in sealed plastic bags labeled with disinfection status.3. All packing materials are new prior to transport and are destroyed after use.4. Prescriptions are uncontaminated and are attached to the outside of the bag

containing items sent to the laboratory.

ALGINATE IMPRESSIONS:1. Rinse under running tap water to remove saliva and blood.2. Spray alginate with 5% sodium hypochlorite in a 1:10 dilution mixed daily3. Rinse4. Spray until spray fills indentations5. Wrap in paper towel wetted with sodium hypochlorite6. Store for 10 minutes in closed plastic bag7. Rinse well under cool running water8. Pour immediately or transport in clean plastic bag

ALL OTHERS1. Rinse to remove all saliva and blood2. Soak in 5% sodium hypochlorite in a 1:10 dilution bath for 10 minutes3. Rinse

PROSTHESIS/APPLIANCES1. Clean with a sterile instrument brush.2. Rinse under running tap water.3. Apply the following disinfectant:

i. Acrylic dentures – 5% sodium hypochlorite, 1:10 solution – as with impressions

ii. Bite fork with wax, wax registrations - 5% sodium hypochlorite, 1:10 solution – spray while avoid metal breakdown from sodium hypochlorite - 10 minutes

iii. Metal and acrylic or metal and porcelain – for 10 minutes

Rinse thoroughly again and dry.Transport acrylic items in plastic bag.Bite forks to be cleaned and sterilized after stone mounting

STONE CASTSRinse with running water.Spray with 5% sodium hypochlorite 1:10 dilution until wet. Allow to dry.

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STERILIZE WITH STEAM VAPOUR

DISINFECT WITH SURFACE DISINFECTANT

Spatulas Rubber bowlsStones, burs Articulators/face bows (not fork)Brushes Shade guidesWater baths Glass slabsFacebow forksImpression traysOrtho bands, arch wires, bracketsOrtho pliers

*Rag wheels

*Rag wheels are difficult to clean. They should be thoroughly rinsed, soaked in a 1:10 sodium hypochlorite bath for 10 minutes, rinsed, dried, then sterilized – similar to cleaning cloths which is where this rationale comes from. However, this method lacks complete evidence and should only be accompanied by use of the ragwheel on prosthesis and appliances that have been disinfected prior to use of the ragwheel.

OUR OFFICE POLICY:A. SENDING TO LABORATORY� Follow recommended procedures as outlined above.� Other (describe those procedures which are handled differently with rationale)

B. UPON RETURN FROM LABORATORY� Rinse case well after returning from laboratory

C. Communication with our laboratory to determine how they handle our cases:� Follow recommended procedures as outlined above� Other (describe those procedures which are handled differently with rationale)

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Dear Participants,

In preparing this Manual, there may be a feeling that this is a contractual arrangement between the people who are preparing it and the rest of the office. However, by stating what the policy is and who is responsible, there is clarification that will reduce the “worry load” in the office.

The decision to put this material down in writing was made in order to simplify your work load. Please examine the material carefully. Some forms will need to be copied or duplicated several times.

I trust that you will find this material useful in assisting to organize your Infection Control Policies and in developing and maintaining up to date practices. The use of textbooks such as Cottone, Terezhalmy, and Molinari’s “Practical Infection Control in Dentistry” and Chris Miller, Charles Palenik’s “Infection Control and Management of Hazardous Materials for the Dental Team” are invaluable as a resource.

Excellent websites for information for infection control include: Health Canada, Center for Disease Control (CDC) and “OSAP” (Organization for Safety and Asepsis).

Thank you on behalf of your patients for caring about their safety!

Dr. Nita Mazurat mazuratn@cc.umanitoba.ca1-204-789-3695

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