Greetings from Procter & Gamble, I am Dr. Terezhalmy and my two colleagues associated with this video presentation of COMPETENCY-BASED INFECTION PREVENTION FOR ORAL HEALTHCARE SETTINGS are Ms. Blake and Dr. Lavigne.
All three of us have done consulting work for Procter & Gamble and are members of the dentalcare.com Advisory Board.
The objectives are to facilitate compliance with specific competencies identified by the CDC for direct observation and documentation.
Upon completion of this module healthcare personnel should be able to:
Identify competency-based elements of infection control practices.
Demonstrate competency in the following infection control practices under direct observation:
Performing hand hygiene
Donning and removing personal protective equipment
Recycling the dental treatment room
Processing contaminated instruments
Demonstrating respiratory hygiene and cough etiquette
The transmission of pathogenic organisms in oral healthcare settings is rare, yet infection does present a potential hazard.
Infection is the invasion and multiplication of microorganism in body tissues causing local tissue injury as a result of competitive metabolism, toxin production, and immune-mediated reactions.
The transmission of infectious agents in healthcare settings requires four elements: a source or reservoir of infectious agents; a susceptible host; a portal of entry receptive of the agent; and a mode of transmission of the agent.
Modes of transmission include direct contact with blood and other potentially infectious material, often called (OPIM); indirect contact with blood and OPIM, such as contact with contaminated objects; exposure to splash, spatter, and splatter contaminated with blood and OPIM; and, finally, inhalation of airborne microorganisms in aerosols, such as droplets and droplet nuclei.
Pathogenic organisms in the oral healthcare settings include Hepatitis-B and Hepatitis-C viruses; the HIV virus; mumps, measles, rubella; herpes simplex and varicella zoster viruses; influenza and syncytial viruses; group A streptococci; Mycobacterium tuberculosis; and emerging pathogens, such as methicillin-resistant staphylococcus aureus or MRSA, Ebola virus and others.
The hierarchy of prevention strategies include immunization, hand hygiene, personal protective equipment, engineering and work-practice controls, environmental infection control, transmission-based precautions, respiratory hygiene and cough etiquette, post-exposure evaluation and follow-up and, finally, administrative and work practice controls.
Ongoing education and competency-based training of healthcare personnel are critical for ensuring that infection prevention policies and procedures are understood and followed.
Key recommendations for education and training of healthcare personnel are job and task-specific and must be provided upon hire, repeated annually and when policies and procedures are updated or revised and they must focus on both healthcare personnel and patient safety.
Specific competencies identified by the CDC for direct observation and documentation include performing hand hygiene, donning and removing personnel protective equipment, environmental cleaning of the dental treatment room, instrument reprocessing, such as sterilization and disinfection procedures, respiratory hygiene and cough etiquette.
Natural or artificial fingernails should be kept short to facilitate thorough cleaning and prevent glove tears.
All jewelry should be removed from the hands and wrists as they interfere with glove use and become a source of contamination.
Sinks with electronic foot or knee action faucet controls are recommended.
The preferred method of hand hygiene depends on the degree of contamination, the type of procedure to be performed, and the desired persistence of antimicrobial action.
Options include routine handwash, hand antisepsis, such as antiseptic handwash and antiseptic handrub, and surgical hand antisepsis.
ALWAYS WASH HANDS WHEN VISIBLY SOILED, otherwise use an antiseptic handrub. Routine handwash removes soil and transient microorganisms. It is an acceptable method prior to performing physical examinations and nonsurgical procedures, and the duration of the entire procedure is about 40 to 60 seconds.
Technique and Products
Step 1: Wet hands under warm running water.
Step 2: Apply enough antimicrobial soap, plain soap, to cover all surfaces.
Step 3: Rub hands palm-to-palm.
Step 4: Rub right palm over left dorsum with interlaced fingers and vice versa.
Step 5: Rub palm to palm with fingers interlaced.
Step 6: Rub back of fingers to opposing palms with fingers interlocked.
Step 7: Rotational rubbing of left thumb clasped in right palm and vice versa.
Step 8: Rotational rubbing, backwards and forwards with clasped fingers of the right hand in left palm and vice versa.
Step 9: Rinse hands under running warm water.
Step 10: Dry hands thoroughly with single-use towel.
Step 11: Use towel to turn off faucet. Once dried, the hands are safe.
The technique is the same as for routine handwash. The product is an antimicrobial soap usually containing povidone iodine, 5 to 10%. It removes or destroys transient microorganisms and reduces the resident flora. It is considered to be an acceptable method prior to performing physical examinations and nonsurgical procedures. The duration of the entire procedure is 40 to 60 seconds.
The PREFERRED METHOD FOR HAND HYGIENE when there is no visible soil on hands. It removes or destroys transient microorganisms and reduces resident flora. It is an acceptable method prior to performing physical examinations and nonsurgical procedures. The duration of the entire procedure is 20 to 30 seconds.
Technique and Products
Step 1: In a cupped hand apply a 60 to 95% alcohol-based product either ethanol or isopropanol.
Step 2: Rub hands palm-to-palm.
Step 3: Rub right palm over left dorsum with interlaced fingers and vice versa.
Step 4: Rub palm-to-palm with fingers interlaced.
Step 5: Rub back of fingers to opposing palms with fingers interlocked.
Step 6: Rotational rubbing of left thumb clasped in the right palm and vice versa.
Step 7: Rotational rubbing backwards and forwards with clasped fingers of right hand in left palm and vice versa.
Step 8: Once dry, hands are safe.
Surgical Hand Antisepsis
Option 1: Perform routine handwash. Rub hands and forearms vigorously for 40 to 60 seconds followed by an antiseptic handrub. Rub hands and forearms vigorously for 20 to 30 seconds.
Option 2: Antiseptic handwash. Rub hands and forearms vigorously for 2 to 5 minutes.
Personal Protective Equipment
Personal protective equipment should not permit blood or OPIM to reach street clothes; undergarments; skin; mucous membranes, such as the mouth, eyes, nose, and respiratory epithelium.
Personal protective equipment in oral healthcare settings include surgical gown, surgical mask or particulate filter respirator, protective eyewear, such as goggles or a face shield and task specific gloves - nonsurgical, surgical or heavy duty utility gloves.
Surgical gowns must have long sleeves. They must be changed at least daily and anytime it becomes visibly soiled. As soon as possible when penetrated by blood or OPIM, and they should be removed before leaving the work area and placed in a waste container for disposal or a designated receptacle for washing.
Surgical mask is a standard precaution – must cover both nose and mouth, must have a 95% filtration efficiency for particles greater than 3 microns in diameter, should be changed as soon as possible when mask becomes wet between patients or even during patient treatment.
Particulate filter respirators are used for respiratory precaution - must cover both nose and mouth and must have a 95% filtration efficiency when challenged with particles less than 0.3 of a micron in diameter. They also must be certified by the National Institute for Occupational Safety and Health or NIOSH.
Protective eyewear, goggles with solid side shields or a face shield must be worn by healthcare personnel for procedures likely to generate splash, splatter, spatter, and aerosols. Similar precautions shall be in effect for all patients.
Task-specific gloves, non-surgical and surgical gloves are single-use items. When torn or punctured, they must be changed as soon as possible. Gloves must never be washed as it causes wicking - penetration of liquid through undetectable holes in gloves. Double gloving is acceptable in certain extensive surgical procedures. Heavy-duty utility gloves must be worn for all instrument, equipment, and environmental surface cleaning and disinfection.
The type of personal protective equipment used will vary depending on the level of precautions required, such as standard vs airborne precautions. The procedure for putting on or removing personal protective equipment is tailored to the specific type of personal protective equipment used.
Sequence of putting on personal protective equipment:
Step 1: Perform appropriate hand hygiene. Once dry, hands are safe.
Step 2a: Put on a gown. It must fully cover torso from neck to knees, arms to end of wrists.
Step 2b: It should wrap around the back and be fastened in the back of neck and waist.
Step 3a: Put on a mask or a particulate filter respirator. Secure ties or elastic bands at the middle of the head and neck.
Step 3b: Fit flexible band to nose-bridge.
Step 3c: Fit snug to face and below chin. If wearing a particulate filter respirator, fit check.
Step 4: Put on goggles or face shield. Place over eyes and/or over face and adjust fit.
Step 5: Put on gloves; extend to cover wrist of gown.
Personal protective equipment are to be removed without contaminating clothing, skin, or mucous membranes with potentially infectious materials before exiting the patient’s room except the particulate filter respirator. If worn, it must be removed after leaving the patient’s room and closing the door.
Sequence of removing personal protective equipment:
Step 1: Remove gloves using a gloved hand, grasp the palm area of the other gloved hand and peel off first glove. Hold removed glove in gloved hand, slide fingers of ungloved hand under remaining glove at wrist and peel off the second glove over first glove. Discard gloves in a waste container. THE OUTSIDE OF GLOVES IS CONTAMINATED - DO NOT TOUCH! If the hands get contaminated during glove removal, perform appropriate hand hygiene immediately.
Step 2: Remove goggles or face shield. From the back lift the head band and ear piece and place in a designated receptacle for reprocessing. THE OUTSIDE OF GOGGLES AND FACE SHIELD IS CONTAMINATED - DO NOT TOUCH! If the hands get contaminated during goggle or face shield removal, perform appropriate hand hygiene immediately.
Step 3: Remove the gown. Unfasten ties, ensure that sleeves do not contact body when reaching for the ties. THE FRONT AND SLEEVES OF GOWNS ARE CONTAMINATED - DO NOT TOUCH! If the hands get contaminated during gown removal, perform appropriate hand hygiene immediately.
Step 4: Remove surgical mask. IF A PARTICULATE FILTER RESPIRATOR IS WORN, DO NOT REMOVE. It is to be removed after leaving the treatment room and closing the door. Grasp bottom ties or elastic of the mask, then the ones at the top without touching front, discard in a waste container. THE FRONT OF MASK OR RESPIRATOR IS CONTAMINATED - DO NOT TOUCH! If the hands get contaminated during removal, perform appropriate hand hygiene immediately.
Step 5: Perform appropriate hand hygiene before leaving treatment room. Once dry, hands are safe.
The particulate filter respirator is to be removed after leaving the treatment room and closing the door, without touching the front. Discard in a waste container. Perform appropriate hand hygiene immediately after removing respirator. Once dry, hands are safe.
Environmental Infection Control in the Dental Treatment Room
The dental treatment room is the direct patient care setting, it is central to the delivery of oral healthcare. Recommendations that follow are sufficiently flexible to serve as a template for other areas that support the delivery of clinical services.
Perform appropriate hand hygiene. Place protective plastic covers on clinical contact surfaces, such as headrests, dental unit, control switches, air and water line hoses, light handles, chairside light curing unit, and other hard-to-clean areas and equipment. Have appropriate instrument packs and supplies ready to begin treatment. This includes all the necessary personal protective equipment for provider, assistant, and patient.
Examine the sterilized instrument packs and packages to ensure that they have not been compromised. Confirm that the external chemical indicators have changed to the appropriate color. Do not open packs in advance of the patient's arrival.
Seat the patient. Place patient napkin. Provide the patient with safety goggles. Open sterilized instrument packs, trays, and cassettes with clean, ungloved hands. Do not touching the content. Confirm that internal chemical indicators have changed to the appropriate color. Leave wrapping material underneath the trays, packs, or cassettes as a barrier to the work surface. Perform appropriate hand hygiene and put on personal protective equipment. Connect hand pieces, air and water syringes, saliva ejector, and high-volume evacuation tips. Proceed with planned treatment.
Upon completion of treatment, remove disposable sharps from cassettes, trays, and packs, such as needles, local anesthetic cartridges, orthodontic wires, scalpel blades, suture needles, endodontic files, and broken instruments. Place disposable sharps in a rigid, puncture-resistant, leak-proof labeled or color-coded container located in the dental treatment room. Remove other regulated medical waste from the cassette trays or packs, such as blood- or saliva-soaked cotton rolls, gauze, pellets, tissue coverings or surgical packs. Place regulated medical waste in a rigid, puncture-resistant, leak-proof labeled or color-coded container lined with a biohazard bag located in the dental treatment room. Flush devices connected to water and air lines for 20-30 seconds, such as hand pieces, ultrasonic scalers, air and water syringes. Disconnect hand pieces, air and water syringes, saliva ejector, and high-volume evacuation tips. Place all contaminated instruments, including trays and cassettes, into a sealable, puncture resistant, leak proof container displaying a biohazard symbol. Remove gloves and perform appropriate hand hygiene. Don a fresh pair of gloves. Transport container of contaminated instruments to the receiving side of the central processing area. Return to the dental treatment room without touching any environmental surfaces on the way back. Remove and dispose of all disposable barriers. Clean and disinfect clinical contact surfaces that were not barrier protected. Use an EPA-registered intermediate-level hospital disinfectant with a tuberculocidal claim. Remove personal protective equipment and perform appropriate hand hygiene. Prepare the dental treatment room for the next patient.
Securing the Dental Treatment Room at the End of the Day
Wearing appropriate personal protective equipment, empty and clean amalgam trap container per dental unit manufacturer’s recommendations. Flush and clean the high value evacuation system per manufacturer’s recommendation. Flush water lines and suction hoses. If waterline treatment products are used, follow manufacturer’s instructions. Clean dental unit water bottles; follow manufacturer’s instructions. Clean and disinfect all clinical contact surfaces using an EPA-registered intermediate-level hospital disinfectant with tuberculocidal claim. Remove personal protective equipment and perform appropriate hand hygiene.
Sterilization and Disinfection of Reusable Patient-care Items
Reusable patient-care items fall into three categories: non-critical, semi-critical and critical.
Non-critical items contact only intact skin during their intended use. Semi-critical items touch mucous membranes and non-intact skin during their intended use. Critical items penetrate soft tissues and bone during their intended use.
The central processing area must be of adequate size with four successive stations. They include receiving and cleaning; preparation and packaging; sterilization or disinfection; and, finally, storage of sterilized units, such as individual packs, peel pouches, containers, and so forth.
Non-critical items MUST be cleaned and they MUST be disinfected using an EPA-registered intermediate-level hospital disinfectant with tuberculocidal claim. These are products that contain chlorine-quaternary ammonium compounds with alcohol, phenolics, and iodophors.
Heat-sensitive critical and semi-critical items MUST be cleaned, and they MUST be sterilized either with ethylene oxide OR an FDA-registered sterilant, such as glutaraldehyde, glutaraldehyde with phenol, hydrogen peroxide, or hydrogen peroxide with peracetic acid.
Heat-tolerant critical and semi-critical items MUST be cleaned and they MUST be heat sterilized.
Wearing Appropriate Personal Protective Equipment
Reusable contaminated patient-care items must be transported from the point of use to the central processing area in a sealable, leak-proof, puncture-resistant container displaying a biohazard symbol.
Receiving and Cleaning
Wearing appropriate personal protective equipment cleaning should be done with minimal splash, splatter, and spatter and in a timely fashion. If visible debris is not removed, it will interfere with microbial inactivation. Use automatic equipment for cleaning, such as an ultrasonic cleaner or a washer/disinfector because these are safer and more efficient than manual cleaning. They do not require presoaking or scrubbing of instruments, and they improve cleaning effectiveness and decrease exposure to blood and other potentially infectious material.
Step 1: Using forceps, transfer contaminated instruments into the strainer-type basket of the ultrasonic cleaner. Process the contaminated instruments in the ultrasonic cleaner according to manufacturer’s recommendations.
Step 2: After the instruments have been cleaned in the ultrasonic cleaner, remove the strainer-type basket. Under running water, rinse instruments in the strainer to remove detergent and other residues.
Step 3: Using forceps, transfer the cleaned instruments onto a clean towel. Inspect instruments for cleanliness, integrity, and function. Remove any residual organic or inorganic debris wearing puncture resistant, heavy-duty utility gloves and a soft long-handled brush.
Step 4: Replace damaged instruments. Dry instruments and remember that some instruments may have to be lubricated according to manufacturer’s recommendations. If the manual method is used, instruments must be soaked in a leak-proof, puncture-resistant container to prevent drying of contaminants. Use a detergent or a detergent-disinfectant combination or an enzymatic cleaner. When cleaning contaminated instruments and devices manually, wear a puncture-resistant, heavy-duty utility gloves and use a soft, long-handled brush.
Preparing and Packaging
Step 1: Individual instruments may be placed in self-sealed or heat-sealed plastic and paper pouches OR they may be arranged in rigid perforated trays or cassettes and wrapped. The packing or wrapping material must allow penetration of sterilization agent to the items being sterilized must maintain the sterility of instruments during transport and storage.
Step 2: Place a process indicator in or on each instrument unit, such as peel pouches, trays, or cassettes. Make sure the process indicator is readily visible in or on each wrapped instrument unit. Write the date and sterilizer number on each instrument unit.
Sterilizing Wrapped Instrument Units
Step 1: Load the chamber of the sterilizer to allow for free circulation of steam around instrument units. Perforated trays and cassettes should be placed parallel to the shelf. Non-perforated containers and peel-packs should be placed on their edges. Small items may be placed loosely in the wire basket.
Step 2: Set physical parameters for each sterilizer with each load, such as time, temperature, and pressure of the sterilizer. Follow manufacturers’ recommendations.
Step 3: Place a biological indicator, or spore test, once a week with a full load. Follow manufacturer’s recommendation for placement in the sterilizer.
Step 4: Once the sterilization cycle is complete, allow the packs to cool and dry inside the chamber. Hot packs act as wicks absorbing moisture and bacteria from hands.
Step 5: Remove the dried and cooled instrument units from the chamber. Inspect all packages for proper color change by visible chemical indicators, and process the spore test in house or have it processed by an independent entity.
Storage of Sterilized Instrument Units
Step 1: Store instrument units in a dry, clean, closed cabinet. Instrument units will remain sterile indefinitely, unless an event causes the package to become contaminated, such as an accidental tear or it becomes wet or it becomes open.
Step 2: Distribution to the point of use. Inspect sterile instrument units to verify barrier integrity and dryness. When the packaging is compromised, torn, wet or open, the instruments should be re-cleaned, re-packed in a new wrap, and re-sterilized. In case of a positive spore test the sterilizer must be removed from service, the date of the last negative spore test is determined, records of physical and chemical monitoring are reviewed to that date. Cleaning, packaging, loading and spore testing procedures are reviewed. If packaging, loading, and operating procedures have been confirmed as performed correctly, then the sterilizer is inspected, repaired, and challenged with three consecutive spore tests without a load. If the three spore tests are negative, all instruments sterilized since the last negative spore test must be re-cleaned, re-packed in a new wrap, and re-sterilized.
Elements of Respiratory Hygiene/Cough Etiquettes
Respiratory hygiene and cough etiquette applies to any person with signs of illness when entering the oral healthcare facility. Such signs include coughing, congestion, rhinorrhea or runny nose, and increased production of respiratory secretions. The absence of fever does not always exclude a respiratory infection. Education of health care personnel, patients, and visitors and posted signs in language(s) appropriate to the population served with instructions to patients and accompanying family members and friends.
Source Control Measures
Cover mouth and nose with a tissue when coughing or sneezing. Dispose used tissue in a waste basket. After contact with respiratory secretions, have source person perform alcohol-based hand rub. If there is no tissue, have the source person cough or sneeze into the upper sleeve or elbow, not the hands. Ask the source person to observe a spatial separation, ideally more than 3 feet from other persons in waiting area. Ask the source person to wear a facemask, if it can be tolerated.
When examining and caring for patients with signs and symptoms of respiratory infection, must observe standard precaution at the very LEAST. If tuberculosis is suspected, they must don a particulate filter respirator.
In summary, to ensure that healthcare personnel adhere to correct infection prevention practices the Centers for Disease Control strongly recommends direct observation of competency-based practices.