OSHA

it was established by the Us Department of Labor when?

1970

MEDICAL WASTE TRACKING ACT

1988 the Medical Waste Tracking Act (MWTA) was signed "Cradle to grave" concept- dental practice is responsible for the hazardous waste it generates until it is destroyed or rendered nonhazardous Toxic waste is a subset of hazardous waste and is capable of having a poisonous effect Many regulations that control the disposal of waste are at the state level, which are more stringent than federal mandates Hazardous waste is any waste that poses a risk or peril to humans or the environment, but does not have to be infectious

OSHA guidelines were voluntary until when?

1991

ENGINEERING CONTROLS

A device, piece of equipment, or technology that removes or isolates a hazard in the workplace

Infection control what is it? goals?

A system of measures practiced by health care personnel. the goal is to decrease transmission of infectious agents.

HAZARD COMMUNICATION STANDARD

Adopted by OSHA in 1989 and updated in 2012 Associated with chemicals in the workplace Employees have a need and a right to know what chemicals are known to be present in their workplace Hazard determination changed to hazard classification Material safety data sheet changed to safety data sheet Labels required to have pictogram, signal word, hazard statement, and precautionary statement

Universal precautions

All blood and body fluids that might be contaminated with blood should be treated as infectious Saliva is considered a potentially infectious material

CLEAN AND DISINFECT THE OPERATORY

All surfaces and equipment that have the potential to become contaminated from hand contact, aerosols, spatter or other contaminated items must be cleaned ▸ Cleaning is required prior to disinfection ▸ If a surface cannot be cleaned, disinfectants will not work and barriers must be used ▸ Noncritical items are materials at risk for contamination but are not used intraorally ▸ Purpose of cleaning is to reduce bioburden ▸Cleansing agents are used, such as water and detergent ▸ More detergent or surfactant, the better the breaking up of debris ▸ Cleaning and disinfecting may be done with one product ▸ All PPE's must be used

ADAA

American Dental Assisting Association

ADA

American Dental Association

ADHA

American Dental Hygiene Association

APIC

Association for Professionals in Infection Control and Epidemiology

sterilization methods

Autoclave- sterilizer that uses steam heat under pressure Dry heat sterilizer Rapid heat transfer sterilizer Unsaturated chemical vapor- chemiclave Ethylene Oxide- chemical vapor sterilizer Chemical sterilants- high level immersion disinfectants, used for items that cannot withstand exposure to heat or ethylene oxide

INSTRUMENT CLEANING

Automated methods use ultrasonic cleaners which break up and loosen debris ▸ Test for effectiveness- use a strip of aluminum foil 2X3 inches for 20 seconds and check in light for small holes, which should be present ▸ Use solutions designed for the machine and don't overload the machine ▸ Rinse instruments both before and after the cycle ▸ Allow to dry completely ▸ Instrument washers may also be used, must be cleared by the FDA ▸ They use much higher temperatures than regular dishwashers

PROCESS OF DISEASE TRANSMISSION

Bacteria, viruses and fungi are found throughout the body and can be carried by blood, saliva, or other body fluids Exposure may be through blood, body fluids or other potentially infectious materials Can occur through direct contact, indirect contact and/or spatter and aerosols.

BARRIER PROTECTION FOR THE OPERATORY

Barriers are used for isolating surfaces with a covering, not as a replacement for cleaning ▸ Barriers are preferred over disinfectants because they reduce exposure to chemicals and save time in operatory processing ▸ Especially useful for items that cannot be effectively cleaned and disinfected ▸ Such as: ridges, grooves, switches, electrical components ▸ Items that are frequently touches should be considered for barrier protection ▸ Such as: saliva ejector holders, tray handles, light switches, light handles, water syringe handle

THREE TYPES OF REGULATED MEDICAL WASTE

Blood and blood saturated materials- Gauze, cotton rolls, etc ▸ Pathological waste- Tissues and extracted teeth, except for amalgam teeth Sharps- Any sharp object used for patient care

TUBERCULOSIS (TB)

Caused by the bacterium M. tuberculosis ▸ Spread through airborne particles known as droplet nuclei ▸ Particles are extremely small in size and normal air currents can keep them airborne for prolonged time periods ▸ Infection may occur when inhaling the droplets, within 2-10 weeks the body's immune system will respond and prevent it from further multiplication and spreading, which is called latent TB ▸ Latent TB usually shows as a positive skin test to tuberculin purified protein derivative (PPD), but it is not active TB and cannot infect others ▸ Routine dental care should be deferred until a patient is no longer infective ▸ N-95 mask should be used if performing dental treatment

CDC stands for what?

Center for Disease Control and Prevention

CHEMICAL SAFETY RECORDS

Chemicals kept in the dental office must be listed ▸ Regular inventory must be taken ▸ Inventory kept for 30 years ▸ Each chemical must have a Safety Data Sheet (SDS) on file ▸ SDS describes the ingredients, hazards and emergency procedures for each chemical ▸ Manufacturer required to prepare the SDS ▸ Employees must have some general knowledge of chemical handling, safety and emergency response in the event of an exposure or spill in, specific to their job duties

Hazardous waste (chemicals, amalgam, etc) generators

Conditionally exempt small quantity generator- less than 100 kilograms small quantity generator- 100-1,000 kilograms large quantity generator- 1,000 or more kilograms

OSHA requires employers to keep information in employees medical records:

Confidential Not disclosed or reported without employees written consent to any person except as required by OSHA Maintained for the duration of employment plus 30 years

PPE'S

Considered a medical device Regulated by the FDA Have a shelf life Potential sensitivity to material

Noncritical

Contacts intact skin (radiograph head/cone, blood pressure cuff)

WORK RELATED INJURY & ILLNESS

Dental offices must report to OSHA any workplace incident that results in a fatality or the hospitalization of three or more employees HIPAA- Health Insurance Portability and Accountability Act, law to protect privacy CDC also requires maintenance of records of work related medical management

INTERMEDIATE LEVEL DISINFECTANTS

Disinfects only Used for clinical contact surfaces Destroys TB, hydrophilic and lipophilic viruses, fungi and vegetative bacteria Examples: Iodophors, alcohol, synthetic phenolics, dual or synergized quaternaries, sodium bromide and chlorine Used for noncritical surfaces

DURING TREATMENT don'ts

Don't reach inside a cabinet for supplies ▸ Use forceps or over gloves if necessary ▸ Don't make notes in the patient's chart ▸ Remember charts cannot be decontaminated ▸ Don't answer the phone ▸ Don't touch your hair, mask or eyewear ▸ Don't touch anything that is not essential for patient treatment ▸ Remove gloves prior to leaving the operatory and perform hand hygiene ▸ Anything at risk for contamination in the operatory must be barrier protected

Hospital-level germicide

EPA registered germicide for disinfecting environmental surfaces in healthcare setting (noncritical surfaces)

ENVIRONMENTAL INFECTION CONTROL

Environmental surfaces are either Clinical Contact or Housekeeping

Standard precautions

Expand upon universal precautions Protect both healthcare workers and patients Treats all patients and materials as potentially infectious

STANDARDS FOR SURFACE DISINFECTANTS

Goal is achieving highest level of disinfection possible Look for phrases like: tuberculocidal, Intermediate-level surface disinfectant, hospital-level disinfectant Should take less than 10 min to kill TB Label must indicate amount of time required to kill TB (which also means it will destroy HIV and HBV) Must be register with EPA, which means has completed minimum scientific testing

MANAGEMENT OF REGULATED WASTE 4 steps

Handling, segregating and storing Labeling Disposing Record keeping

CHEMICAL INDICATORS

Heat sensitive chemicals that display a color or a physical change once the inside of the sterilizer has reached a certain temperature Do not guarantee that sterilization has occurred Indicator used must be specific to the sterilization method used

PREVENTION of Hepatitis B

Hep B is an epidemic in many areas of the world but not the US ▸ Immunization extremely effective ▸ OSHA Bloodborne Pathogens Standard of 1991 stipulates that all healthcare employers must make available and pay for hepatitis B immunizations for all employees who have the potential to be exposed ▸ You do have the right to refuse this immunization but only after you have been informed of the safety and efficacy and potential risk of refusal ▸ Immunization includes 3 injections given intramuscularly, day one, day 30 and day 180 (6 months), then 1-2 moths later a titer antibody test should be taken ▸ 4-6% of individuals may be non-responders and may not develop immunity

HEPATITIS B

Hepatitis is inflammation of the liver ▸ More virulent than other viruses, lives 7 days outside host ▸ Hep B immunization protects from Hep D ▸ Hep B is the most common occupational disease acquired in a dental setting ▸ 2004- 60,000 people newly infected in US ▸ 80% don't show symptoms ▸ Declined 85% from 1990's to 2009 ▸ 50% of people are aware they are infected ▸ Average office seeing 20 pts/day can encounter 1 HBV pt. every 7 days ▸ Immunizations have shown 90% decrease in occupationally acquired HBV

IMMERSION DISINFECTANTS

High level disinfection/sterilization of reusable semi- critical items that cannot withstand heat or ethylene oxide Follow manufacturers directions to achieve sterilization or disinfection Sterilization cannot be verified by biological monitoring Considered medical devices by the FDA Most are hazardous chemicals

HIV

Human immunodeficiency virus ▸ Associated with acquired immune deficiency syndrome (AIDS) ▸ First reported in 1981 ▸ Transmitted via body fluids ▸ Blood containing HIV only survives outside the body while wet and for a period of half an hour or less at room temperature ▸ Symptoms may mimic other infections ▸ According to CDC 20% of persons with HIV are unaware of their status ▸ Risk of transmission after exposure, for healthcare workers is quite low, risk of Hep B and C is higher ▸ No immunization available ▸ Dental healthcare workers may be the first person to suspect or recognize symptoms of HIV in the mouth

MEDICAL TESTING AND INTERVENTION

If an exposure requires medical intervention, the employee should immediately be sent to the designated healthcare provider ▸ Review of the patient's medical history and testing for bloodborne diseases by the health care provider ▸ Circumstances will determine course of treatment ▸ All postexposure evaluations and requirements must be made available to the employee at a reasonable time and place and at no cost to the employee, and performed by a licensed healthcare professional ▸ Treatment is outlined in the book ▸ Workers compensation documentation may be needed

HIGH LEVEL DISINFECTANTS

Immersion high-level disinfection or immersion sterilization Examples: Glutaraldehydes, hydrogen peroxide, paracetic acid Have the ability to kill endospores, TB, hydrophilic and lipophilic viruses, fungi and vegetative bacteria when used according to instructions for immersion disinfection Used to disinfect semicritical items that cannot withstand heat or ethylene oxide sterilization

Working in dentistry puts you at risk of potential exposure incidents in three areas:

Infectious, chemical and physical

6 PROCESSING CYCLE

Instruments must be transported in a holding/transporting container from the operatory to the sterilization area 2. Optional holding solution if not cleaned immediately 3. Ultrasonic cleaning 4. Instrument packaging/Internal chemical monitoring/ Labeling 5. Sterilization process/Mechanical monitoring/ Biological monitoring 6. Instrument storage

SAFETY DATA SHEETS

Must have required specified headings in a specified sequence OSHA wants a consistent format to improve effectiveness

HANDLING SHARPS 7 don'ts

Never pass sharps in a manner that might cause injury ▸ Never recap needles using two hands ▸ Never disengage a capped needle from a syringe by hand ▸ Dispose all non reusable sharps in a sharps container ▸ Never wipe debris from an instrument with gauze ▸ Never fulcrum on the same tooth you are working on ▸ Always hold instruments by the handle and one at a time

SHARPS SAFETY AND THE NEEDLESTICK PREVENTION ACT

New devices used for needlestick safety should be screened, evaluated by those who will use them, and forms should be kept in the written Exposure Control Plan as documentation of the OSHA mandate

TRANSMISSION

Organism enters the body through various routes Best option-prevent infection in the first place through all controls Direct contact, indirect contact and spatter and aerosols Chapped skin, splashes to the eyes or nose, inhalation to the throat or lung, skin wound, needlestick, etc Parenteral contact Cross contamination/cross infection occurs when you, or your patient, has an infection and that infection is passed along to there staff members, family, or friends

OSAP

Organization for safety, Asepsis and Prevention.

PACKAGING OF INSTRUMENTS

Packages should be labeled with date of sterilization, cycle number and type of instruments (unless packaging is clear), name or initials of packager, and sterilizer used ▸ Label packages prior to sterilization ▸ Hinged instruments should be packaged in the open position ▸ Gauze may be placed around sharp instruments to prevent piercing of the package ▸ Packaging materials used depend on the type of sterilization equipment ▸ Sterilization of unwrapped instruments is not recommended but may be done in specific situations

YOUR ROLE IN THE OFFICE BESIDES HYGIENE

Product selection Purchasing Inventory control Research Keep up to date on new products and information to make informed choices The salesperson is not always right Follow manufacturers directions for products

PERSONAL HYGIENE

Proper personal hygiene is necessary before putting on PPE's Hair, fingernails and jewelry harbor high levels of microorganisms ▸Hair should be pulled back form the face and pinned without hanging on either side the face or neck ▸Mustaches and beards must be neatly trimmed to be covered by a mask ▸ Nails should be short and no artificial nails No hand jewelry should be worn especially with gloves

PERSONAL PROTECTIVE EQUIPMENT

Protect yourself against the risk of occupational exposure EX. Gloves, masks, eyewear, clinical clothing

PPE order

Protective clothing/Lab coat Eyewear Mask Gloves

HEPATITIS C

Spread primarily through blood contact, sexual transmission or during pregnancy Not an increased risk by healthcare workers New medications that actually treat Hep C called Sovaldi

KEY FACTORS FOR CHOOSING DISINFECTION CHEMICALS list 7

Staff/patient compatibility, nontoxic Storage requirements Ease of use User satisfaction Shelf life Disposal Cost

Dental practices use written reports for:

Standard Operating Procedures Employee Health Records Employee Training Records Emergency Procedures Plans Chemical Safety Records Dental Waste Miscellaneous

HOUSEKEEPING RECORDS

Suggested to keep unless otherwise specified by state law Sterilization monitoring log Biologic monitoring log Equipment maintenance and repair Dental unit waterline maintenance log Housekeeping schedule

biological method of sterilization

The only method to verify sterilization ▸ Paper strips or glass vials containing non-pathogenic highly resistant bacterial endospores ▸ When processed correctly, the endospores are killed ▸ CDC, ADA and OSAP recommend biologic monitoring be done on a weekly basis ▸ Requirement depends on state ▸ Incubation testing is usually done by an independent lab ▸ If results are positive for endospores, sterilizers must not be used until fixed

DENTAL WATERLINES

The plastic tubing is frequently contaminated with large numbers of potentially pathogenic microorganisms

EXPOSURE CONTROL MANUAL

The practice's training and safety program manual Location of the manual Government stipulations are that all employees be aware of its contents and prescribed procedures

TRANSMISSION-BASED PRECAUTIONS

These are precautions for infection prevention in the care of patients who are infected with highly contagious pathogens spread through airborne, droplet or contact routes ▸ Methicillin-resistant Staphylococcus aureus (MRSA)- spread on transiently contaminated hands of health care professionals, by contact. May live several weeks outside host ▸ Chickenpox/Varicella Zoster, Flu/Influenza- spread through droplets, N95 mask recommended ▸ Tuberculosis (TB)- spread through airborne

TRAINING DOCUMENTATION

Training must be documented to verify compliance Kept for three years Information needed: Date and length of training Conductor of training and qualifications Names and job titles of attendees Content of training OSHA may request copies of OSHA training records

Five primary controls or protection methods:

Universal/Standard Precautions Work practice Controls Engineering Controls Personal Protective Equipment Environmental Infection Control Clinical Contact Surfaces Housekeeping Surfaces

transporting instruments

Use a container that is puncture resistant, leakproof with solid sides and bottom and has a biohazard label, a lid would be valuable Wear appropriate PPE's and utility gloves

To minimize and protect yourself from aerosolization and splatter do what?

Use high-volume evacuation (HVE) Use a dental dam Use correct PPE's Use a preprocedural mouthrinse for each patient to reduce microbial dose load

face shields

Used for certain dental procedures ▸ Ultrasonic scaling, air polishing and high-speed handpieces may generate large volumes of water ▸ Should have crown and chin protection and wrap around the face to the point of the ear ▸ If made of high impact plastic and large enough, can be worn without protective eyewear ▸ Usually worn with face mask ▸ May be single-use, disposable, or reusable type that must be decontaminated

LOW LEVEL DISINFECTANTS

Used for general housekeeping and clinical contact surfaces not contaminated with blood Destroys certain viruses and fungi but not TB Example: simple quaternary ammonium compounds, detergents

Utility gloves

Used for handling contaminated sharps or chemicals ▸ Should be puncture or chemical resistant ▸ Made of many materials, depending on need ▸ Sanitized after use ▸ Not a medical device, not regulated by FDA

Patient examination gloves

Used for patient care, examinations, other nonsurgical procedures involving contact with mucous membranes and laboratory procedures ▸ They are non sterile and single-use ▸ Made of many materials, most common latex and nitrile ▸ Considered a medical device regulated by the FDA

Overgloves

Used for prevention of cross contamination

HOLDING SOLUTION

Used if instruments cannot be cleaned immediately after patient treatment ▸ Basically a soaking solution to prevent debris from drying on the instrument ▸ Made of noncorrosive liquid, preferably with a surfactant, stored in a hard-walled, spill proof container with a lid ▸ Not necessary if instruments cleaned soon after use ▸ Solution should be changed twice a day or more when visibly cloudy

EPA definition for disinfectants

Used on hard inanimate surfaces and objects to destroy or irreversible inactivate infectious fungi, viruses and bacteria, but not necessarily endospores

Medical waste generators

Very small quantity generator Less than 50lbs of regulated medical waste Most dental offices are in this category

CHEMICAL HAZARD COMMUNICATIONS PROGRAM has 5 main parts

Written program ▸ Chemical inventory- updated as new chemicals are used and reviewed annually, should be accessible to all employees ▸ Safety Data Sheets- should be accessible to all employees, including household products brought to the office ▸ Do not throw out old SDS for no longer used chemicals, store in different binder ▸ Container labeling- helps to avoid hazards or potential hazards ▸ Employee training- in all above aspects

exposure control manager

assigned to manage the practice's training program and ensure documentation is properly maintained

infectious agent

bacteria fungi virus

Infectious waste must be handled and disposed of as___________

biological hazard (biohazard)

SDS has procedures for

cleaning up chemical spills and first aid for that specific chemical

Biofilm

colonization of slime protected microbial communities that may harbor bacteria, fungi, protozoa and microscopic nematode worms

Semicritical

contacts mucous membranes or non-intact skin (mouth mirror, impression trays, dental handpieces)

There are three categories for instrument processing

critical semi critical noncritical

OSHA mandates what?

employers must "furnish to each of his employees, which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees."

Infectious waste is defined by _______, ___________, and __________regulations

federal, state, and local

3 types of training

initial training additional training annual training

Hospital level disinfectants

most critical to infection control and use on dental instruments, floors, walls, bed linens, toilet seats and other surfaces

OSHA stands for what?

occupational safety and health administration

CDC guidelines for Infection Control in Dental Healthcare Settings 2003

only sterile fluids should be used for procedures in which bone is exposed ▸ Mostly for periodontal and oral surgery procedures ▸ This requires a sterile disposable or sterilizable water delivery system

Critical

penetrates soft tissue, contacts bone, enters into or contacts the bloodstream or other normally sterile tissue (surgical instruments, periodontal scalers)

Ability of an organism to infect and cause disease depends on both the _________ and _______

potential host infecting agent

in 1987 what 4 things did OSHA add?

production transportation usage storage disposal of chemicals

annual training

required for specific OSHA standards such as the Bloodborne Pathogens Standard. recommended as good office policy.

what 4 things does the CDC do?

review current scientific info and create recommendations to protect the health of the population. Tracks disease trends across the country and investigates disease outbreaks that threaten public health. Designed to protect workers and patients. Control speed of infection from workers to patients, patient to worker and between patients.

the exposure control manager is responsible for?

scheduling and monitoring training for all personnel. maintaining training material and records. customizing the course for the office setting. answering questions and providing ongoing training. determining where, how and which employees are at risk.

clean and disinfect steps

spray wipe spray

Low level disinfectants

the major source of products used in households, swimming pools and water purifiers

Disinfection

the process of decontamination, which kills most microorganisms, with the exception of spore-forming organisms left on a surface after cleaning

Cleaning

to remove visible debris and dirt by use of a detergent and mechanical means prior to disinfection and/or barrier protection

Other federal, state and local authorities regulate the __________ and ___________ of infectious waste after it leaves the dental office

transportation disposal

With _________, ______________ or a__________, aerosols and spatter are created

ultrasonic scalers high- speed handpicks air/water syringes

exposure control

uses the concepts and strategies of infection control to prevent exposure to infectious agents and limit the spread of infectious agents when exposure occurs. these programs are part of the offices standard operating procedures and practices and should be routinely evaluated.

additional training

when there are changes in policies, procedures, or products. if new info is available or if there are changes in recommendations or regulations. if someone does not follow standard operating procedures.

initial training

whenever there is a change in responsibilities of staff or infection control manager. whenever the is a change in office procedures were the is a potential for an occupational exposure/hazard. in response to changes in government regulations or recommendations.