SAA Webinar - Infection Control in Portable/Mobile Oral Healthcare–Different From Private Practice?

Smiles Across America Webinar Series

Infection Control in Portable and Mobile Oral Healthcare Settings – Different From Private Practice?

Date: 10/20/2015

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Infection Control in Portable Dental Settings: Different from Private Practice?

IMPLEMENTING A CULTURE OF SAFETY IN YOUR PRACTICE

Kathy Eklund, RDH MHP The Forsyth Institute Organization for Safety, Asepsis and Prevention

Disclaimer • The speaker is not an official representative of any federal or state agency ( e.g. CDC, OSHA).

• This presentation is not intended to endorse or promote any specific product or company.

• Visual images of products are for example purposes only, and do not infer endorsement by the speaker.

• Kathy J. Eklund

What is OSAP? vision Every visit is a safe dental visit.

mission

To be the world’s leading provider of education that supports safe dental visits.

community Clinicians, policy makers, educators, companies: individuals and organizations sharing the vision.

• Collaborative effort for increased commitment to infection control • Curated resources for CDC/OSHA compliance • Support for infection control coordinator • Help promoting a culture of safety • Sample patient communications • Social media posts #SafestDV • Alerts on emerging threats/new information

Go to www.osap.org to learn more.

Public Trust & Expectations

What is an Infection Prevention and Control Program?

A system of policies, procedures and practices that when successfully implemented, will minimize the risk of transmission of pathogenic microorganisms. The goal is to prevent: •healthcare-associated infections in patients •injuries and illnesses in healthcare personnel

The Chain of Infection Pathogens of Sufficient Virulence and Numbers to Cause Infection

Susceptible Host One who is not immune

Portal of Entry Mucos Membrane GI Tract Respiratory Broken Skin

Break the Chain

Reservoir or Source Blood, Water

Standard Precautions Immunizations

PPE

Sterilization

Hand Hygiene

Mode of Transmission Direct or indirect Contact Droplet Airborne

Summary A

variety of infectious agents can be transmitted in dental settings through contact, droplet and airborne modes

Standard

precautions remain the major infection prevention strategy to prevent transmissions

Hepatitis

B and C virus transmission in healthcare remain preventable risks Reported transmissions associated with dental healthcare settings are rare.

Infection Prevention and Safety Program

Regulations, Guidance, Standards

Patient & Personnel Safety Individual Provider, Practice, Institution (SOPs, Ethics)

Professional Standards, Best Practices

“… the recommended infection control practices are applicable to all settings in which dental treatment is provided.” www.cdc.gov/oralhealt h

ForsythKids

Infection Control Policies and Procedures • Should be supported by an authoritative source

Implementing Change

Proactive

Reactive

CDC: The Infection Control Coordinator • An infection-control coordinator, knowledgeable or willing to be trained, should be assigned responsibility for coordinating the program.

Checklists for Repeatable Processes • Remind individuals of critical steps to complete each time • Provide verification that the steps have been completed • Create a history that can be reconstructed if there is an adverse event

www.osap.org

OSAP Resources

OSAP Resources OSAP From Policy to Practice OSAP’s Guide to the CDC Guidelines: http://www.osap.org/?CDCGuidelinesCourse -7 module distance learning continuing education program • Incorporating the CDC Guidelines into your dental practice OSAP turned the Centers for Disease Control and Prevention (CDC) Guidelines for Infection Control in Dental Health-Care Settings - 2003 into a checklist for dental practice settings.

OSAP Resource for Portable and Mobile Dental Programs •Guidance on Infection Control Considerations for Dental Services in Sites Using Portable Equipment or Mobile Vans : http://www.osap.org/?page=PortableMobile •Guide for Safety and Infection Control for Oral Healthcare Missions. OSAP 2004. Available at: http://www.osap.org http://www.osap.org/?page=ICOralHCMissions

IC Checklist for Dental Settings Using Mobile Vans or Portable Dental Equipment •The guidance tools are designed to: •help dental programs determine what factors present challenges to providing safe, quality care and •make decisions about possible adaptations or the need to select another site to provide services.

• The forms • are formatted to answer specific questions about the site, personnel and procedures.

Tool/Form - Site Assessment •The Site Assessment tool is best used when considering a new site to deliver services, although existing sites also should be assessed to determine possible problems that may have been overlooked or have not yet been addressed •For mobile vans, questions would relate to both the van and the site where it is parked. www.osap.org •http://www.osap.org/resource/resmgr/Checkli sts/OSAP.siteassessment.checklis.pdf

Infection Control Considerations for Dental Services in Sites Using Portable Equipment or Mobile Vans

Name and Type of Setting: ______________________________________________

Date of assessment: _______________

Range of Proposed Services: ______________________________________________________________________________________ Acceptable?

Considerations PERSONNEL Site personnel available as point person for fielding questions and concerns Site personnel available for facilitating follow-up of exposures to infectious agents PHYSICAL Reasonably accessible route into/within building to transport equipment and supplies Adequate space for equipment (e.g., chairs, lights, sterilizers) Adequate space for supplies Adequate space for staff movement

Yes

No

Comments N A

Comments

Acceptable?

Considerations Yes PHYSICAL, continued

Adequate room lighting

Waste disposal requirements for regulated and non-regulated waste known and acceptable Ability to cover or clean and disinfect environmental surfaces in service area Adequate ventilation for disinfectants, etc Acceptable housekeeping practices for site and treatment area Site restrictions on chemicals, sprays, etc are known and can be accommodated

No

NA

Yes

OSAP Infection Control Checklist for Dental Programs Using Mobile Vans or Portable Dental Equipment http://www.osap.org/?page=ChecklistPortable http://www.osap.org/resource/resmgr/Checklists/OSAP.che cklist.portabledenta.pdf

ON SITE CHECKLIST

Infection Control Checklist and Risk • Organized around the level of anticipated contact with mucous membranes, blood or saliva contaminated with blood or no anticipated contact with mucous membranes, blood or contaminated saliva.

• Assess absence of resources • Adherence to accepted infection control practices; hand hygiene, PPE, immunizations; handling of sharps; management of exposures, reusable and single use patient items; management of medical waste; and dental unit water quality • Strategies for implementing CDC recommendations • http://www.osap.org/resource/resmgr/Checklists/OSAP.checklist.portablede nta.pdf

Tool/Form On -Site Infection Control Checklist • ALL PROGRAMS SHOULD MEET THE MINIMUM REQUIREMENTS BASED ON THE CENTERS FOR DISEASE CONTROL AND PREVENTION’S (CDC) GUIDING PRINCIPLES OF INFECTION CONTROL • Use the appropriate column to help inform your provision of safe dental care to your particular program

Level of Risk •I. Anticipated contact with the patient’s mucous membranes, blood or saliva visibly contaminated with blood.

•II. Anticipated contact with the patient’s mucous membranes but not with blood or saliva visibly contaminated with blood.

•III. No anticipated contact with the patient’s mucous membranes, blood, or saliva visibly contaminated with blood.

• Adapted from Summers, et al. JADA 1994

Risk Level I • The provider anticipates contact both with the patient’s mucous membranes and blood or saliva contaminated with blood: for example, during scaling, using an air-water syringe, etc.

Risk Level II • Contact with the patient’s mucous membranes, but not with blood or saliva contaminated with blood • oral health survey that includes using a mouth mirror and dental explorer, fluoride varnish application or sealants.

• Use of an air/water syringe, however, would raise risk to a Level I.

Risk Level III • No contact with the patient’s mucous membranes or blood or saliva contaminated with blood • oral health screening limited to a visual inspection of the oral tissues • using a disposable tongue blade or mirror for retraction or an explorer to only check a tooth surface for sealants.

www.wuortho.com/palo-altocommunity.html

PPE and Screenings – Using Volunteers – other issues

Determine the Level of Risk Levels of Anticipated Contact Between Provider and Patients During Oral Health Surveys, Screenings, and Treatment

Anticipated Contact With:

Mucous Membranes (MM)

Blood or Saliva Contaminated with Blood

I

Yes

Yes

II

Yes

No

III

No

No

Level*

* Adapted from Summers, et al. JADA 1994

Level I

Level II

Level III

INFECTION CONTROL PRACTICE Yes

X

X

X

Infection Control Program Operating Procedures Is there a written infection control program?

Is there a designated person(s) responsible for program oversight?

Are there methods for monitoring and evaluating the program?

Is there a training program for dental health-care personnel (DHCP) (initial and ongoing) in infection control policies and practices?

X

X

X

Immunizations Are DHCP adequately immunized against vaccine-preventable diseases? Immunizations should meet or exceed federal, state and local guidelines. (May not be necessary for screenings)

Only if DHCP

Hepatitis B

Annual Influenza Additional immunizations needed for program: X

X

X

Hand Hygiene

Are sinks available close to the area where care is provided?

No

Comments

Level II

Level III

INFECTION CONTROL PRACTICE

Level I

X

Yes

X

Safe Handling of Sharp Instruments and Devices Are DHCP trained in the safe handling and management of sharps?

Are sharps containers safely located as close as possible to the user?

Is there a written protocol for transporting and disposing of sharps and sharps containers?

X

X

Management and Follow-Up of Occupational Exposures Is there a written policy and procedures manual for post-exposure management?

Is there a designated person responsible for post-exposure management?

Is there a mechanism to document the exposure incident?

Where is the closest medical facility for wound care and postexposure management?

Is there a mechanism to refer the source and DHCP for testing and follow-up?

Is there a mechanism for expert consultation by phone?

No

Comments

Level II

Level III

INFECTION CONTROL PRACTICE

Level I

X

Yes

X

X

Hand Hygiene, Continued If not, are alcohol-based hand sanitizers available?

Is staff properly trained in the use of alcohol handrub products?

X

X

Personal Protective Equipment (PPE) (e.g., gloves, masks, protective eyewear, protective clothing) Wear mask if Is there a protocol that outlines what PPE are worn for which have respiratory procedures? infection Is PPE storage available and close to care?

Are facilities available to disinfect PPE (DHCP eve wear, patient eyewear, heavy duty utility gloves)?

X

X

As necessary

Environmental Surfaces: Clinical Contact Surfaces (e.g., light handles and countertops)

Is there a list of what surfaces will be cleaned, disinfected or barrier protected and the process and products to be used?

If chemical disinfectants are used, is there a protocol for how they are managed, stored and disposed?

X

X

Housekeeping Surfaces (e.g., floors, walls) Is there a list of which housekeeping surfaces will need to be cleaned and disinfected and how often?

No

Comments

Principle 1 Take Action to Stay Healthy

Principle 2 Avoid Contact with Blood and OPIM

Principle 3 Limit the Spread of Blood and OPIM

Principle 4 Make Patient Care Items Safe for Use

Summers C, et.al. Infection Control for Screening and Surveys. JADA 1994;125:1213-

Principle 1 - Take Action to Stay Healthy •Protect with immunizations •Report occupational exposures to blood •Perform hand hygiene •Keep hands healthy Principle 1 Take Action to Stay Healthy

Recommended Vaccines for HCP Based on Risk of Healthcare Setting Transmission* Hepatitis B

Give 3-dose series. Give IM. Obtain anti-HBs serologic testing 1-2 months after dose #3

Influenza

Give 1 dose of TIV or LAIV annually. Give TIV intramuscularly or LAIV intranasally. Follow 2013 recommendations from CDC

MMR

HCP born in 1957 or later without evidence of immunity or prior vaccination, give 2 doses MMR, 4 weeks apart.

Give SC. If born before 1957, 1 dose. Two doses for all HCP during mumps outbreak.

Varicella

HCP with no serologic proof of immunity, prior vaccination, or history of varicella disease, give 2 doses of varicella vaccine, 4 weeks apart. Give SC.

Tetanus/diphtheria/pertussis

All HCP need Td every 10 years after completing a primary series. Give 1 dose of Tdap IM, if direct patient contact, prioritize HCP in contact with pts. <12 mos.

*MMWR November 25, 2011 / 60(RR07);1-45

Pre-Exposure Serologic Assessment • Because vaccine-induced anti-HBs wanes over time, testing HCP for antiHBs years after vaccination might not distinguish vaccine nonresponders from responders.

• Guidance: Pre-exposure assessment of current or past anti-HBs results upon hire or matriculation, followed by one or more additional doses of HepB vaccine for HCP with anti-HBs <10 mIU/mL, if necessary, helps to ensure that HCP will be protected if they have an exposure to HBVcontaining blood or body fluids.

• CDC Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus Protection and for Administering Postexposure Management

Recommendations and Reports December 20, 2013 / 62(rr10);1-19 http://www.cdc.gov/mmwr/preview/mmwrhtml /rr6210a1.htm?s_cid=rr6210a1_w

Tuberculin Skin Test (TST)

TB Blood Test Identifies if a person was exposed to MTB

Primed peptide TH1 cells create interferon

TB Testing Frequency Risk category

Frequency

Low

Baseline on hire; further testing not needed unless exposure occurs

Medium

Baseline, then annually

Potential ongoing transmission

Baseline, then every 8â&#x20AC;&#x201C;10 wks until evidence of transmission has ceased

Conclusions Vaccines

have been highly successful in reducing the burden of many diseases

Vaccination

are a critical component of infection control to protect HCP and their patients, coworkers and families

DHCP

should be  Assessed for vaccination and immunity status at the time of hire and at least annually to ensure they are up to date with recommended vaccines.  Provided with information about risks and benefits of the vaccines

CDC: Hands Need to be Cleaned •When visibly dirty •After touching contaminated objects with bare hands •Before and after patient treatment ( before glove placement and after glove removal)

Hand Hygiene/Antisepsis for Routine Dental Procedures Soap & Water

Anti-microbial Soap & Water

Alcohol-based Hand Rub Alone

If hands are visibly soiled with blood, body fluids, or proteinaceous material

YES

YES

NO

If hands are not visibly soiled

YES

YES

YES

Principle 2 Avoid Contact with Blood and Other Potentially Infectious Materials •Personal Protective Equipment •Safe handling of sharp instruments Principle 2 Avoid Contact with Blood and OPIM 56

Personal Protective Equipment • A major component of standard precautions.

• Protects the skin and mucous membranes from exposure to infectious materials in spray or spatter • Should be removed when leaving treatment areas

57

Recommendations for Gloving •Wear gloves when contact with blood, saliva, mucous membranes is possible •Remove gloves after patient care •Wear a new pair of gloves for each patient

58

Facemasks and Protective Eyewear What corrections should be recommended?

PPE • Wear long-sleeved disposable or reusable gowns, lab coats, or uniforms that cover skin and personal clothing likely to be soiled with blood, saliva or infectious material • Change if visible soiled, or as soon as possible • Remove all barriers before leaving patient care or laboratory areas

http://www.cdc.gov/vhf/ebola/pdf/ppe-poster.pdf

61

Find the Errors

62

Single-Hand Debridement of Scaling Instruments

63

Postexposure Management Program Develop clear policies and procedures that reflect • Employer Obligations un OSHA BBP Standard • Current CDC Guidance • Other Considerations (temporary workers, volunteers, etc.)

• Educate dental health care personnel (DHCP) • Education and training strategies • Provide rapid response following an exposure incident: • Facilitate appropriate exposure response/first aid, • Complete initial exposure report • Refer DHCP to qualified HCP (risk assessment, baseline testing, and post-exposure prophylaxis) • Document source patient and request testing for HIV, HBV, and HCV, unless +sero-status known •

Percutaneous Exposure Incident

Remove instrument or syringe/needle

Report Injury to designated on-site manager

Provide exposure response “first aid”

Complete initial report

Refer exposed DHCP to qualified HCP

Post-exposure site –specific evaluation

Request source patient testing

Obtain written report from HCP

Principle 3 Limit the Spread of Contamination •Set up the operatory before starting treatment: unit-dose supplies •Cover surfaces that may become contaminated •Minimize sprays and splashes •Properly dispose of medical waste Principle 3 Limit the Spread of Blood and OPIM

Limit the Spread of Blood and OPIM Use evacuation to control spatter

Avoid Contamination (touching)

67

Environmental Surfaces

Clinical Contact

Housekeeping

68

Environmental Stability • HBV can survive in dried blood on environmental surfaces for at least one week.

• In vitro studies have shown the HCV can remain infective on dry surfaces for up to 6 weeks.

• HBV and HCV transmission via contact with environmental surfaces has been demonstrated in investigations of outbreaks among patients and staff of hemodialysis units.

Bond WW et al, Lancet 1981 Kamili S et al, Infect Control Hosp Epidemiol 2007 Paintsil E, J Infect Dis 2014.

Clinical Contact Surfaces

70

Barriers •Remove •Replace

VS.

Cleaning and Disinfection •Spray •Clean/wipe •Spray

Clean and disinfect using an EPA registered low- ( HIV/HBV claim) to intermediate- (tuberculocidal claim) level hospital disinfectant 71

Clinical Contact Surfaces â&#x20AC;˘ Use surface barriers and change between patients OR â&#x20AC;˘ Clean and disinfect using an EPA registered low- to intermediatelevel hospital disinfectant

Premoistened Disinfectant Wipes • Wipe (clean) • Wipe (disinfect) • Wait (manufacturer’s claim) • Follow specific Product Manufacturer’s Instructions for use.

Barriers and Complex Equipment

74

Where are the infection control errors?

75

Managing the Portable Dental Unit • Aseptic Management for transport and set-up • Maintenance • Dental Unit Water Quality Management • Transport - Occupational Health Considerations • Lift training • Weight limits • Containment

76

Non-regulated and Regulated Medical Waste Regulated Waste Non-regulated Waste

• • • •

Saturated materials Hard and soft tissues Sharps (needles, burs, wires, blades, etc.)

Disposable sharp instruments

Care site rules regarding disposable PPE waste?

77

Sharps Containers • Policy and SOPs – Place used sharps in puncture-resistant containers – Dispose of sharps close to point of use – Containment and transport of sharps containers to and from care sites

78

Principle 4 Make Reusable Patient Care Items Safe for Use • Clean, heat sterilize or disinfect reusable patient care items that ….

• Monitor processes….

• Contain and dispose of single use items • Considerations for onsite vs. centralized processing of re-usable patient care items.

Principle 4 Make Patient Care Items Safe for Use 79

Dental Handpieces & Other Devices Attached to Air & Waterlines

In the Olden Days

81

Alternative Slow Speed Handpieces â&#x20AC;˘Hygiene Handpieces

Managing Clean Supplies Good

Needs improvement

Storage of Patient Care Items and Supplies - What is in the box?

84

How do you manage sealant dispensers/syringes to prevent contamination?

Transport of Contaminated Sharps • Bloodborne Pathogens Standard 1910.1030 • (3) When moving containers of contaminated sharps from the area of use, the containers shall be: • (i) Closed immediately prior to removal or replacement to prevent spillage or protrusion of contents during handling, storage, transport…

Heavy Duty Utility Gloves • Handling contaminated sharp items during post procedure clean-up and in sterilization area.

• Puncture and chemical resistant.

• Sizable.

• May wash or surface disinfect.

• Discard when cracked, peeling, torn, punctured or when ability to protect is compromised.

Proper Work Flow Prevents Errors

Photo Courtesy of Eve Cuny, MS

Home Instrument Processing?

Challenges for Compliance with Recommendations and Standards Not a dedicated Sterilization Area

This is not a dedicated Sterilization Area

OSAP INFECTION CONTROL BOOT CAMPâ&#x201E;˘ January 11-13, 2016 in Atlanta, GA 24 hours of CE "Boot Campâ&#x20AC;? covers all the basics in infection prevention and safety. The course is a crucial building block for every dental professional with infection control responsibilities.

Attendees receive a comprehensive resource binder, checklists, tools and much more.

Go to www.osap.org to learn more.

Thank You

keklund@forsyth.org

Question and Answer Session • Questions are welcome! This session may last for 10-15 minutes.

• Write your questions in your control panel on the upper right hand of your screen.

• Submit questions at any time.

CE Credit Available

Contact Information Kathy Eklund keklund@forsyth.org Tyler Brown tyler.brown@oralhealthamerica.org