PPE and disinfection
Fit Test Process
Most often a qualitative fit test will be provided. This method involves the introduction of an aerosol test agent into an area around the face/head of the user. A determination is made whether or not the wearer can detect the presence of the agent through the means of odor, taste or nasal, irritation. Once it is established the wearer can detect the agent, a respirator is selected to best fit the facial type and the wearer is guided through performing exercises as outlined in the OSHA Respiratory Protection standard.
Chairside Adjustment:
- Wear appropriate PPE for the procedure - Rinse the prostheses thoroughly with water to remove saliva, blood, other debris. - When adjusting an appliance or prosthesis chairside outside patient's mouth make sure your assistant is holding the HVE very close to the head of the hand piece to reduce aerosols or if an assistant is not present, work close to the HVE which is turned on.
WHY ARE ALCOHOL-BASED HAND RUBS SO GREAT?
Alcohol-based hand rubs (foam or gel) kill more effectively and more quickly than handwashing with soap and water. They are less damaging to skin than soap and water, resulting in less dryness and irritation. They require less time than handwashing with soap and water. Bottles/dispensers can be placed at the point of care so they are more accessible.
Health Mointoring
All staff, students, and faculty, will be required to monitor their health. A telehealth service through the Greater Philadelphia Health Action is an option that is offered to staff. This service will provide consultation with a nurse practitioner, consultations, prescriptions, and scheduling of testing for flu or COVID-19. Dental commuity members are also offered to enter their synmptoms in the database organzied by TUHS Occupational Health Unit. All clearances to return to work will be issued by Occupational Health.
WHEN SHOULD I USE ALCOHOL-BASED HAND RUBS?
An alcohol-based hand rub is the preferred method for hand hygiene in all situations, except for when your hands are visibly dirty or contaminated.
[Slide #14]
Another example of where you should wear a non-medical mask is in those settings where a physical distance of at least one meter cannot be achieved. This includes public transportation such as buses, metros, trains or a plane; also for specific working conditions where the employee is in close contact or potential close contact with others, such as social workers, cashiers or servers. Again, the purpose of this is for source control.
HAND RUB (foam and gel)
Apply to palm of one hand (the amount used depends on specific hand rub product). Rub hands together, covering all surfaces, focusing in particular on the fingertips and fingernails, until dry. Use enough rub to require at least 15 seconds to dry.
BUT I DIDN'T TOUCH THE PATIENT. WHY SHOULD I PRACTICE HAND HYGIENE?
Bacteria can survive for DAYS on patient care equipment and other surfaces. Surfaces in the patient care environment - including bed rails, IV pumps, and even computer keyboards - are often contaminated with bacteria. It's important to practice hand hygiene after you leave the room, even if you only touched patient care equipment or other surfaces.
Dental Team Preparation:
1. Ensure dental health care personnel have received their seasonal flu and when appropriate the pneumonia vaccine by the end of October of each year. Vertification is required. 2. Dental health care personnel should not report to work if experiencing influenza-like-illness (ILI) which includes fever with cough, sore throat, muscle aches). The school will follow HR policies on reporting to work and verification during the COVID-19 pandemic. 3. Dental health care providers who fall into one of the high risk categories may request accomodations by contacting Dr. Leona Sperrazza or Ms. Bonny Reeder who will work with Human Resources to manage each case individually. 4. Dental health care personnel (students, residents, staff and faculty) should self-monitor by remaining alert to any respiratory systems (cough, shortness of breath, sore throat) and check their temperatures twice daily regardless of presence of other symptoms consistent with COVID-19. To prevent transmission, dental health care workers should contact their local health department immediately if they suspect COVID-19 infection. In following with TUH protocol, all personnel reporting to work are come into the N. Broad Street entrance of the old dental building and report to the prescreening area. There, staff will be given a surgical mask which will be worn for the duration of their shift. The employee will also be screened for fever and other symptoms. Any employee who is screened with a fever of 100.4°F or higher or responds positive to any one of the screening questions, will be required to: i. Supervisor will be notified they will not be permitted to work ii. Instructed to go home and self-isolate iii. Contact COVID Call Center number at 215-707-6999 for additional instructions on care and returning to work. iv. A practitioner from Occupational Health will contact the employee with next steps. Clinical personnel are to wear appropriate full PPE in clinical treatment areas (dentist, dental assistant working chairside, dental assistants supporting patient care and taking radiographs.) If providing patient care, PPE must be changed in between patients and hands sanitized/washed. PPE that has been contaminated must not be worn outside of treatment areas. 7. All dental health care personnel as well as pre- and post-doctoral students will be required to complete airborne pathogen training and go through the respirator fit-test process which includes the completion and evaluation of a health questionnaire and the fit-test for the type of respirator mask that best conforms to the individuals face to provide an adequate seal. (The respirator fit-test protocoal will be drafted to supplement this document and include support from EHRS as well as in-house trained trainers). 8. When possible, personnel should consider wearing street clothes in and change to clinical clothing and shoes at work and back into street clothes prior to leaving. All personnel are encouraged, upon returning home, to remove clothing and launder with hot water and soap.
[Slide #1]
Hello, welcome to Module 2
Hair cover
Remove from behind the head
Guiding principles
The Novel Coronavirus pandemic (2019-nCoV or COVID-19) has presented several challenges to the practice of dentistry. The experience in Wuhan is that dental providers are at risk unless they are fully protected with advanced personal protective equipment that includes a suit, a full hood covering the head, gloves, covered shoes, and outer protective garment. When the epidemic started in Wuhan these precautionery measures were not implemented and the educational dental hospital was providing regular care. During that period, 9 faculty, staff, and residents were infected (Attachment #1). Following these infections, the hospital terminated all non-elective dental treatments and focused on providing emergency care by small teams (1 oral surgeon, 1 restorative/endodontists, 2 assistants) that treated patients using the same PPE used in the wards where patients with COVID-19 infection were treated. There have been no new cases reported among the small teams after the introduction of the strict PPE method and providing only emergency care. The dental care for patients under the strict PPE followed in Wuhan is not feasible in the US where most dental care is provided in outpatient small private practice. Hence, the question is what to do here to protect patients, providers (denists, assistants, and hygienists), and other staff working in dental clinics. To answer this question we rely on two sources. The first is a critical analysis of what are the sources of infection in a dental clinic (Attachment #2). The current infection control protocols that are approved by CDC and OSHA are sufficient for managing bloodborne pathogens. However, the dental profession and its regulatory bodies have not considered saliva to be as infective as blood. Now, with COVID-19, new infection control guidelines must be established and adhered to in all clinics with different levels of PPE depending on the type of procedure provided. Types of procedures generally fall into two categories: -: aerosol generating and non-aerosol geneating. Dental providers must not only protect themselves from saliva droplets, but also the other members of the dental healthcare team, and patients The mode of transmission of COVID-19 and the role of saliva in its transmission are vital to our understanding. In dental settings, direct transmission can take place via droplets of saliva generated from coughing, sneezing, and inhalation and via direct contact. There is also evidence of fecal-oral transmission. There is no in vivo study on the aerosol generated from dental procedures. A 1994 study identified areas where the aerosol may fall but did not measure aerosol presence in the air of the operatory. A recent in vitro study that generated aerosol using methods not relevant to dental clinical practicefound that the aerosol may persist for around 1 to 2 hour in the air under the experimental condition used in the study (Attachments 3 and 4). To compound matters, transmission can occur from asymptomatic patients. While screening questionnaires targeting symptoms have a role, relying on symptoms to guide our practice is not sufficient The most compelling rationale for the need to move to enhanced infection control standards is the transmission via aerosols during medical and dental procedures, and saliva droplets. During aerosol generating dental procedures (AGDP), droplets or aerosol mixed with the patient's blood and saliva are generated. These particles may stay airborne for extended periods of time or settle on the patient's clothes, dental health care workers' exposed clothing/PPE as well as innatimate surfaces, including cabinets, countertops and floors within the treatment area. Previous research has identified several areas prone to the accumulation of the saliva aerosol which includes the dentist's face not protected by the mask, mask, dominant hand and arm thighs, and hair. All exposed skin that is permitted in the current infection control standards must be covered in the advanced infection control standard. If saliva is a source of viral infection with COVID-19 through aerosolized particles generated during many dental procedures, and saliva droplets, then exposure to saliva should be managed in similarly to the exposure to the human immunodeficiency viruses (HIV). If this guiding principle is accepted, then advanced Personal Protection Equipment (A-PPE) must be used to protect patients, dentists, and staff when provided aeresol generating procedure. The procedures that generate areosols are those that require the use of a handpiece intraorally or any ultrasonic system and that include all procedures that require cutting of tooth structuure, and soft and hard tissues. This document outlines in detail the management of all patients to prevent or reduce the probability of a COVID-19 infection. It is important to note that the majority of patients can be asymptomatic carriers of COVID-19, and hence, the principle of universal precaution must be applied. We have referenced the document developed by the Zhejiang University School of Medicine in Hangzhou, China (Attachment #5).
How long should you rub your hands together when washing with soap and water?
15 seconds
[Slide #1]
Welcome to module 3. Here, we will be discussing IPC in the context of COVID-19.
Which hand hygiene method is less damaging to your skin?
Alcohol-based hand rub (foam or gel)
Which hand hygiene method is more effective at killing bacteria?
Alcohol-based hand rub (foam or gel)
5. Hair Cover
• Must be large enough to cover the entire scalp and hair
HOW DO I PRACTICE HAND HYGIENE CORRECTLY?
hand rub and handwashing
topics
-Donning/doffing posting for non-aerosol procedures (similar to what should have occurred prior to March 16th) -Donning/doffing posting for aerosol procedure - attached -Donning/doffing video for aerosol procedures https://youtu.be/nS00pPC1NZE -Donning/doffing checklist to be used when working with staff (and eventually students) to become comfortable with the process. - attached -Hand hygiene education module https://www.cdc.gov/handhygiene/training/interactiveEducation/ -Outline of before, during, after patient care infection control protocols (attached) -N95 Use and Reuse Policy -Lab Disinfection Protocol -WHO Infection Prevention and Control for COVID-19 Virus course https://openwho.org/courses/COVID-19-IPC-EN -Click on Enroll me now -Create new account -Review all of Module 2: The COVID-19 virus and the following portions of Module 3: IPC in the context of COVID-19 (slides 1-39) {Note: Module 3 is quite lengthy and contains a large amount of good information however it is heavily based on inpatient hospital protocols.}
Process for Reuse
-Obtain a clean, single use paper bag and label the bag clearly with your name. Open the bag and stand it up. -Follow standard procedures for doffing PPE -At the appropriate point in the doffing process, remove the N95 as instructed, avoiding touching the inside of the respirator -Place the N95 in the previously labeled paper bag using caution not to crush or crumple -Perform hand hygiene -Store the bagged N95 in a safe location -Use caution when taking the respirator from the bag for next use by carefully lifting it out by the head/ear straps.
During patient care for aerosol producing treatments:
1) Instruct patient to rinse with 1.5% hydrogen peroxide or 0.2% povidone-iodine rinse for a total of one minute. Suction mouth rinse. (Do not allow patient to create seal around the suction tip with their lips.) 2) Wipe around patient's nostrils then lips with alcohol gauze before and then again after the procedure is complete. 3) For aerosol producing procedures where a rubber dam is not practical, such as with preparing teeth for crowns, the Isovac is to be utilized (Schedule patient for one of the Isovac operatories). Four-handed dentistry utilizing high-volume evacuation must be employed where rubber dam use is not feasible and an Isovac equipped chair is not available. For those procedures where a rubber dam can be utilized, ensure the rubber dam is placed properly to avoid leakage and if available employ a dental assistant. Anti-retraction functions on the handpieces will also provide additional protection against cross-contamination. 4) Limit use of intraoral dental radiographs which are known to increase salivation and potential coughing. Utilize extraoral imaging instead (panoramic or CBCT). 5) Limit use of the air/water syringe due to the forced ejection of air/water that could provoke aerosolization. Additional best practices include (1) use of handpieces with anti-retraction functions; (2) to avoid necessity for post-operative visits, utilize resorbable sutures.
Seating the Patient: (Student)
1) Patient thoroughly washes hands. Seat patient. Review and update medical history. 2) Place head cover and drape on patient/ 3) Open sterile packaging. 4) Wash hands. Don PPE based on procedural protocols for aerosol producing treatments. Proceed according to departmental policy. Donning sequence for aerosol producing treatments: Shoe covers Surgical Gown (level 4) Level 3 face mask (with shield when using loupes with light source) /N95 respirator Head/neck cover Protective eyewear/loupes with solid side shields and full-face shield Examination gloves after washing hands Shoe covers, gowns, masks, head/neck covers and exam gloves are one time use only and must be replaced if they become compromised due to a tear or moisture. If at any time the mask is damaged, soiled, or breathing becomes difficult, the mask is to be removed, discarded in infectious waste and replaced with a new one.
After the patient appointment
1) Provider removes the head cover and drape from the patient gently inverting the outer exposed surface. Discard in infectious waste receptacle. 2) Provider doffs their advanced PPE using the following sequence ensuring each item is inverted to turn the contaminated side of the PPE inward: Examination gloves Face Shield and protective eyewear Head/neck cover Surgical gown Shoe covers Level 3 face mask/N95 respirator 3) Place in infectious waste container. 4) Wash hands. 5) Escort patient to front desk to make next appointment. 6) Relocate to area off clinic floor to complete axium entries with faculty.
To work with the impression/protheses proceed as follows: o Don a new pair of gloves in the lab to polish a prosthesis or pour an impression. o Remove the impression/prostheses from the bag/headrest cover o After completing the lab work, remove burs from the handpiece and rag wheels from the lathe, package them and turn them in to a soiled return dispensary for sterilization. o Rinse and disinfect the prosthesis. o Place in the bag. o Disinfect all the equipment that you used with cavispray. o Perform hand hygiene and return chairside with the disinfected prosthesis in the bag/headrest cover.
16) Prostheses/appliances returned from a commercial lab must go through the disinfection process prior to placing in the patient's mouth unless the packaging indicates it had been disinfected at the laboratory.
Before Seating the Patient: (Student)
1) Wash hands. Do examination with gloves and protective eyewear. 2) Ensure the disinfectant water bottle is full. Switch the toggle right above the water bottle off and disconnect the bottle. Bring it to the dispensary to have it filled. Reattach to dental unit. 3) Flush all water lines (2 minutes prior to first patient visit). 4) Clean and disinfect all clinical contact surfaces using Cavicide 1 (or other EPA registered disinfectant that is effective against coronavirus please see: https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2 These surfaces include bracket table tops, counters, light handles, switches, drawer and cabinet handles and should be disinfected utilizing the following protocol: Spray → Wipe (clean) → Spray→ Wait (based on manufacturer's recommendations) → Wipe Caution: Keep the spray nozzle close to the surfaces to avoid creating a plume of chemical aerosols 4) Place plastic wrap on light handles, bracket handles, light electrical switches, across the control panel, and other surfaces (keyboard and screen) that will be touched during patient care. 5) Attach saliva ejector tip, high-speed evacuation tip, sterile handpiece, and sterile three-way syringe tip. 6) Place plastic barrier sleeves over saliva ejector, high-speed evacuation, air/water syringe connections, computer keyboard and mouse and chair cover over the operatory chair. 7) Obtain two teaspoons of 1.5% hydrogen peroxide (Colgate© Peroxyl) or povidone-iodine (Betadine ® or IoRinse ®pretreatment mouthrinse). 9) Set up all items used during delivery of care required for designated procedure. Instrument cassettes and other sterilized wrapped items are to remain in the wrap and closed until such time as the patient is seated and the attending faculty has had the opportunity to check for sterility and provide approval for the planned procedure. Carefully, think through the procedure to ensure everything needed for the visit is obtained prior to seating the patient and beginning care. 10) After completing the operatory set-up, remove gloves and protective eyewear. Wash hands thoroughly with soap and water for a minimum of 20 seconds.
Preparation of the Facilities:
1. Handsanitizing stations placed at the main entrances, waiting areas and reception desks. 2. Remove all reading materials, magazines, toys and other items from the waiting areas that may be hard to disinfect. 3. Place appropriate signage in waiting areas regarding the standards of respiratory hygiene and cough/sneeze etiquette. 4. Instruct patients to not bring companions except when absolutely necessary (special needs, elderly, pediatric patients, etc). These individuals will need to be screened as well as the patient upon arrival. Anyone who does not have a true purpose for being present will be asked to remain outside or in their car. 5. Patient appointments should be staggered to minimize contact with others in the waiting area. 6. Waiting area seating should be modified to ensure social distancing. 7. Conduct inventory of available PPE supplies.
Process for Fit Testing
1. Health Evaluation - requires user to complete two health evaluation forms. 2. Preparation for Fit Test Process 3. Fit Test Process 4. Wearing an N95 Respirator 5. Recommended Guidance for Extended Use and Limited Reuse of N95 Respirators 6. Process for Reuse 7. Recommendations for When to Discard an N95 Respirator
DONNING (PUTTING ON) PPE AT TEMPLE UNIVESITY MAURICE H KORNBERG SCHOOL OF DENTISTRY
1. perform hand hygiene 2. shoe cover 3. gown 4. face mask or respirator 5. hair cover 6. loupes (or other eye protection) and face shield) 7. gloves 8. staff, residents, students may now enter patient area general work clothes are neither intended to protect against hazard nor considered PPE - put on ppe in the following sequence to reduce the possibility of contamination
Disinfecting protocol for impressions, appliances and prosthesis going to the commercial or in-house laboratory:
Chlorine compounds are a universal disinfection solution for impressions, appliances and prostheses. A one part hypochlorite (bleach) to 3 parts water solution will be available in spray bottles. 1) With clean ungloved hands obtain two plastic bags or headrest covers 2) Put on gloves 3) Rinse impression or prosthesis in the sink thoroughly 4) Spray impression thoroughly in the sink with the bleach solution 5) Place disinfected impression/appliance in first bag/headrest cover 6) Leave impression in plastic bag for 10 minutes 7) Remove gloves and perform hand hygiene 8) Don new pair of gloves 9) Remove impression/prosthesis from the plastic bag and rinse thoroughly under water 10) Remove glove from one hand and open second bag/headrest cover with non-gloved hand 11) Place the impression/prosthesis in the second bag 12) Set down bag without touching with the contaminated glove 13) Remove gloves and perform hand hygiene 14) Doff PPE and leave clinic with the second bag 15) Follow procedure to submit impression/prostheses to Soble Lab OR
Hand hygiene
Clean hands with alcohol-based sanitizer
[Slide #38]
Cleaning refers to the first step required to physically remove contamination by foreign material. It will also remove organic materials such as blood, secretions, excretions and microorganisms to prepare a medical device for disinfection or sterilization. Disinfecting refers to the process to reduce the number of viable microorganisms to a less harmful level. This process may not inactivate bacterial spores prions and some viruses and thus sterilization is needed. Sterilization is a validated process used to render an object free from viable microorganisms as mentioned above. These include viruses bacterial spores but not prions.
DONNING
Collect PPE in appropriate size Prepare to don PPE Inspect PPE Perform hand hygiene Don shoe covers Don surgical gown Don face mask or respirator Don hair cover Don loupes (or other eye protection) and face shield Don nitrile gloves Final inspection
Infection control standards for providing non-aerosol producing dental procedures (N-AGDP):
Dental health care personnel should minimally adhere to standard precautions which are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient. This includes hand hygiene, use of PPE, respiratory hygiene/etiquette, sharps safety, safe injection practice, sterile instruments/devices, clean and disinfected environmental surfaces. Existing standard precautions for dental care will be followed including the following personal protective equipment (PPE) for all providers (dentist, dental hygienist and dental assistant). 1. Protection eyewear/goggles with sideshields 2. Masks: level 3 surgical w/ or w/out shield 3. Medical level 2 or 3 disposable gown 4. Examination gloves
Don nitrile gloves
Extend gloves over cuff of gown
7. Gloves
Extend to cover wrists of gown NOTE: Gloves must be removed as soon as feasible when torn, cut, or punctured. Hand hygiene must be done before regloving.
1. Recommended Guidance for Extended Use and Limited Reuse of N95 Respirators
Extended use- the practice of wearing the same N95 respirator for repeated close contact encounters with several patients, without removing the respirator between patient encounters. Recommended for use in areas where multiple patients are seen in a given session such as Oral Surgery, Emergency Endodontics, Faculty Dental Practice, Graduate Clinics. Reuse- the practice of using the same N95 respirator for multiple encounters with patients but doffing/removing it after each encounter. The respirator is stored in between encounters to be donned/put on prior to the next encounter with a patient.
Perform hand hygiene
Follow proper hand hygiene protocol w/ alcohol-based hand sanitizer
[Slide #17]
For a demonstration on how to properly wear and remove a mask, please visit our website as there have now been some updated videos.
DOFFING
Gloves Hand hygiene Gown Hand hygiene Shoe covers Hand hygiene Loupes (or other eye protection) and face shield Hand hygiene Hair cover Hand hygiene Face mask or respirator Perform hand hygiene
[Slide #7]
The clinical management guidance has been updated as of the 27th of May and includes an updated case definition based on case severity. Please refer to this document for more details as it is being updated frequently. It also includes some of the most common symptoms that have been reported such as fever, cough, fatigue, anorexia, shortness of breath, myalgia, and other nonspecific symptoms such as sore throat, nasal congestion, headache, diarrhoea, nausea and vomiting.
Addendum to Temple University Kornberg School of Dentistry Infection Control Maual May 30, 2020
Guiding principles Social distancing Spread of the aerosol during dental care Screening patients with travel history or with symptoms. Health Mointoring Testing for COVID-19 Dental Team Preparation: Preparation of the Facilities: Infection control standards for providing non-aerosol producing dental procedures (N-AGDP): Lebvel 3 masks instead of N95? Infection control standard for providing aerosol generating dental procedures (AGDP) Before Seating the Patient: (Student) Seating the Patient: (Student) During patient care for aerosol producing treatments: After the patient appointment Disinfection of the dental operatory: ADA Decision Trees for Managing Postive Patients with COVID
STANDARD PRECAUTIONS INCLUDE:
Hand hygiene (handwashing with soap and water or use of an alcohol-based hand sanitizer) before and after patient contact and after contact with the immediate patient care environment. Personal protective equipment (PPE) when exposure to blood, body fluids, excretions, secretions (except sweat), mucous membranes, or non-intact skin is anticipated. PPE includes:Gloves - when hand contamination is anticipated.Masks and eye protection - when splashes may occur.Gowns - when soiling of clothes may occur.
DO YOU USE HAND HYGIENE WHEN YOU SHOULD?
Healthcare personnel practice hand hygiene about half the time they should. Hand hygiene is often not practiced: Immediately before touching a patient, performing an invasive procedure, or manipulating an invasive device Immediately after touching a patient, contaminated items or surfaces, or removing gloves After removing gloves After touching items or surfaces in the immediate patient care environment, even if you didn't touch the patient while you were there
[Slide #33]
Here, we show some scenarios of when you should wear the various kinds of PPE. I won't go through them all but please take some time to look at this chart.
WHY IS HAND HYGIENE IMPORTANT?
Infections are a serious problem in healthcare facilities.Every year, an estimated 2 million patients get a hospital-related infection.90,000 die from their infection. Many infections are transmitted on the hands of healthcare personnel. Hand hygiene is part of Standard Precautions. It can reduce the transmission of healthcare-associated infections - to your patients and to you.
[Slide #10]
Masks are part of a comprehensive package of measures to suppress transmission and save lives. The use of a mask alone is insufficient to provide an adequate level of protection. The package of measures includes that people with symptoms suggestive of COVID-19 should stay at home and call their health care provider. Suspect cases should be tested for COVID-19. Confirmed cases should be isolated and contacts of those confirmed cases should be quarantined for 14 days. Everyone should avoid touching their face and if they wear the mask, the front of the mask. Everyone is encouraged to clean their hands frequently and thoroughly and keep a distance of at least one meter from others. The community should be informed about the disease and engaged in these measures. What hasn't changed from previous guidance is that the recommendations for healthcare workers when caring for a COVID-19, suspect or confirmed case, remain the same. The recommendations are for contact and droplet precautions: that means medical masks, gown, gloves and eye protection to be used when caring for a suspect or confirmed COVID-19 patient. For aerosol generating procedures and or settings, the use of respirators is encouraged.
[Slide #12]
Medical masks are meant to provide both a protective barrier from others and source control from the wearer. Thus, they are encouraged for health workers or anyone taking care of a sick person, for anyone with symptoms suggestive of COVID-19 and for those vulnerable populations which includes those aged 60 and above and those with underlying health conditions. Non-medical masks or fabric masks are intended as source control and thus are meant to protect those around the mask wearer. They are intended for people in the general public in settings where at least one-meter distance cannot be maintained. This includes public settings such as workplaces, buses, metros, shopping stores, etc... It also includes essential workers who may be in close contact with the general public during their work.
1. Health Evaluation - requires user to complete two health evaluation forms.
OSHA Respirator Medical Evaluation Questionnaire (complete in its entirety) Respiratory Medical Clearance Form (complete the left side box only) Predoctoral and postdoctoral students are to submit these documents via Faculty and staff are to forward the completed documents to Dr. Jay Mobo, Employee Health, at [email protected] Preferably, a secured means, such as TUsafesend, should be used to forward you health information. "Dental Fit Testing" as the subject/title of your message so that he is able to quickly identify the reason for your communication. A doctor from Student Health Services or Occupational Health respectively, will reach out for clarification on any component of the medical evaluation should further information be needed in order to make an appropriate assessment. Once cleared by Student Health Services or Occupational Health, a communication will be received noting such. At that time, you will be reached to arrange a date and time for the fit testing.
HAND HYGIENE TECHNIQUES VIDEO TRANSCRIPT
One key element to protecting yourself and protecting others is proper hand hygiene. Even if your hands appear clean, the process of removing and handling soiled equipment could result in unseen hand contamination. Hand hygiene can be performed with an alcohol-based hand rub or by hand washing. If a hand rub is used, dispense the product onto the palm of one hand and rub hands together covering all surfaces until hands are dry. If your hands are visibly contaminated, they must be washed using soap and water. The first step is to wet your hands and apply a small amount of liquid soap into your palm. Rub vigorously until lather appears and continue for at least 15 seconds. Be sure to scrub between your fingers, under your fingernails, and the back of your hands as well as the palm up to your wrists. Then, rinse your hands under running water. Dry your hands with a disposable towel. Using the towel as a barrier, turn off the faucet.
[Slide #35]
PPE should be immediately changed if it becomes contaminated or damaged. PPE should not be adjusted or touched during patient care. Specifically, make sure to never touch your face while wearing PPE. If there is concern or breach of these practices, leave the patient care area when it's safe to do so and remove and change your PPE. And always keep in mind to remove carefully as to avoid self-contamination.
[Slide #5]
Physical distancing, also known as social distancing, is one of the key measures of infection control and key recommendations that you have heard about during this outbreak. It refers to keeping a physical distance of at least one meter from others as well as ensuring healthcare facilities are designed in such a way that ensures patients are seated away from each other in waiting areas and that patient beds and other activities are at minimum one meter apart. For group settings such as in cafeterias in the healthcare facilities, we recommend workers do not sit next to each other or share meals or other items. We also recommend staff visitors and others to avoid unnecessary touching or close contact.
Preparation for Fit Test Process
Prior to arrival, please do not take anything by mouth (drink, food, candy or gum) within 30 minutes of the assigned date and time so as not to interfere with the test process. Bring the eyeglasses, goggles, loupes or other protective eyewear that would normally be utilized when providing patient care to ensure they do not impact the fit of the respirator. Facial hair must be removed or styles so as not to interfere with the seal of the respirator. (Please see attached diagram)
[Slide #13]
Slide 13 outlines examples of where the use of a medical and non-medical mask should be considered for the general public. For example, in areas where there is intense community transmission and there is limited or no capacity to implement the other containment measures such as physical distancing, contact tracing, appropriate testing and isolation and care for suspected or confirmed cases. The general public is advised to wear a non-medical mask in places like grocery stores, at work, social gatherings, mass gatherings, schools, etc....The purpose of this would be for source control. So, if they were infected and did not yet know it, they would be protecting those around them by wearing a mask. Another setting that encourages the use of a non-medical mask is in those that have high population density where physical distancing cannot be achieved and all of the other containment measures are also limited. This includes people living in cramped conditions and specific settings such as refugee camps, camp-like settings or slums. Again, the purpose of this is for source control. Please take a minute and go through these examples in more detail.
[Slide #3]
So what is a coronavirus? Coronaviruses are large family of viruses that cause a wide range of illness from the common cold to more severe diseases as we've seen in the Middle East Respiratory Syndrome or MERS and Severe Acute Respiratory Syndrome or SARS. A novel coronavirus or nCoV is a new strain that has not been previously identified and has reached humans. SARS-CoV-2 was identified as the coronavirus strain responsible for causing COVID-19 disease.
[Slide #24]
So, hand hygiene. We have evidence to prove that this is the best way to prevent the spread of germs in the healthcare setting and in the community at large. We know that our hands are our main tool for work as healthcare workers and they are the key link in the chain of transmission. Think about this when you are going to touch door handles, touching medication, touching your phone, instruments and touching patients in their environment.
[Slide #30]
So, how to promote respiratory hygiene in a healthcare facility? This is where healthcare workers should be encouraging hand washing for patients with respiratory symptoms, providing them with masks if they are to leave the room and these patients should be kept away from other patients in their own single room or at least one meter away with a mask on. There should be visual aids such as posters all around the healthcare facility for patients and visitors with respiratory symptoms to cover their cough and practice respiratory etiquette as we previously mentioned and hand hygiene. So, please consider having masks and tissues available for patients in all areas.
[Slide #20]
So, recommendation number one: applying standard precautions for all patients.
[Slide #34]
So, some of the principles for using PPE. Always clean your hands before and after the wearing of the PPE. PPE should be available by the healthcare facility, when and where it is indicated. So this should be outside patient care rooms and inside if you anticipate needing PPE for some sort of activities. They should be provided in the correct size and you should be selecting these according to risk or per the precautions noted for the patient. They should always be put on before contact with the patient and their environment. They should always be immediately removed after completing the task and leaving the patient care area. PPE should never be reused. However, if you have some sort of reusable PPEs, these should be cleaned and disinfected after every use.
Perform hand hygiene
Wash hands or utilized alcohol-based hand hygiene utilizing appropriate technique
[Slide #32]
So, we talked earlier about the risk assessment and standard precautions. Risk assessments mean that the risk of exposure and extent of contact that you anticipate with blood, body fluids, respiratory droplets or open skin. Once this is done, you should select which PPE items to wear based on this assessment. Transcription OpenWHO: MOOC_COVID-19_IPC_Module3 8 You should be performing hand hygiene according to the WHO five moments for hand hygiene and this should be done for each patient, each time you encounter them. So think about building this into your routine: as you're walking towards a patient's room you should automatically be thinking what does the patient have and how can I protect myself.
[Slide #18]
So, what IPC strategies are recommended by WHO for COVID-19?
[Slide #37]
So, what is decontamination? This is the process that removes soil and pathogenic organisms from objects so that they are safe to handle, safe to process, safe to use and to discard.
WHAT ARE STANDARD PRECAUTIONS?
Standard Precautions are a set of infection control practices that healthcare personnel use to reduce transmission of microorganisms in healthcare settings. Standard Precautions protect both healthcare personnel and patients from contact with infectious agents.
WHEN SHOULD I USE STANDARD PRECAUTIONS?
Standard Precautions should be used byhealthcare personnel caring for patientsregardless of the patient's diagnosis and whether or not the patient is known to have a communicable infection. In other words, Standard Precautions should be used for all patients, all the time.
[Slide #36]
Standard precautions also include the steps to safe injections. So, this means you should always have a clean workspace, perform hand hygiene, perform medication preparation with sterile safety-engineered syringes, sterile vial of medications. You should perform skin cleaning and antisepsis, an appropriate collection of sharps and appropriate waste management.
ADA Decision Trees for Managing Postive Patients with COVID
TUKSOD will follow the decision alogoirthim proposed by the American Dental Association. At the present time, and until negative pressure rooms are built, the dental school will treat patients with no clinical evidence of infection with COVID-19. Once the facility is ready, we will treat COVID-19 positive patients.
[Slide #4]
The "IPC during healthcare when COVID-19 is suspected" is the main IPC technical guidance document. It outlines WHO advice for COVID-19 for healthcare workers and healthcare facilities and in other settings as well as for the general community. The main recommendations are the following: first, we encourage physical distancing which means you should avoid close contact with people suffering from acute respiratory infections. These are people that are coughing, sneezing and are clearly unwell. Next, we recommend frequent hand hygiene, especially after direct contact with sick people or their environments. Also, for people with symptoms of acute respiratory infection, we recommend they practice respiratory etiquette, they wear a medical mask and they seek medical care if in respiratory distress.
[Slide #6]
The "Rational use of PPE" document was updated in April to include strategies to optimize the availability of PPE. There is a link at the bottom of the slide where you can access this document for more details.
Testing for COVID-19
The Greater Philadelphia Health Action will test any staff, student, or faculty, who would like to bested using molecular test kits analyzed throut LABCorp. Resulys will only be shared with the tested individuals.
[Slide #19]
The IPC strategies to prevent or limit transmission in healthcare settings include the following: applying standard precautions for all patients, ensuring triage and early recognition and source control, as well as implementing empiric additional precautions for suspected cases of COVID-19 - these are droplet and contact precautions -, in addition, implementing administrative controls and using environmental and engineering controls.
[Slide #9]
The advice on the use of masks for COVID-19 was recently updated on the 5th of June. This document provides advice on the use of masks in various settings such as healthcare, home care and in the community. It is intended for decision makers, public health and infection prevention and control professionals as well as health care workers and individuals in the community. The updated information on transmission from symptomatic, pre-symptomatic and asymptomatic people infected with COVID-19 was the basis for this new guidance. It includes information on what type of mask to wear in different settings and by various Transcription OpenWHO: MOOC_COVID-19_IPC_Module3 3 populations as well as new research on non-medical masks with regards to the ideal types of fabrics, number of layers, composition and the shape of homemade fabric masks. WHO overall guidance for decision makers remains the same: WHO advises decision makers to apply a risk-based approach for advising on mask use in the community. More information can be found at the bottom of this slide in the link.
[Slide #6]
The airborne route of transmission is due to small droplet nuclei aerosol particles that are mainly limited to circumstances and healthcare settings in which aerosol generating procedures are performed, such as tracheal intubation, non-invasive ventilation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation or bronchoscopy. Some studies have shown the detection of COVID-19 19 RNA in air samples, however, there are some considerations in these studies. The detection of COVID-19 RNA was in extremely low concentrations well below what could be the infectious inoculum. And the detection of RNA in these samples was also based on PCR based assays and it's not indicative of viable virus replication and infection competent virus that could be transmissible and capable of sufficient inoculum to initiate invasive infection.
Spread of the aerosol during dental care
The dental school in collaboration with EHRS has conducted a study to assess the spread of the aerosol during clinical operations. The patient was Dean Amid Ismail. The operators were two faculty members (dentist and assistant). The final report is attached. EHRS has concluded that: There are no regulatory limits for particle concentration at these sizes. The data shows that particle generation was minimal for all procedures relative to the baseline readings. Dental prophylaxis generated the largest increase in particles compared to the other procedures. Using the ADS with the high-speed suction and Cavitron did not seem to impact particle capture as much as during prophylaxis. Use of the ADS units could be reserved for this type of procedure. TU Purchasing has issued a bid for High Volume Suction Units and a manufacturer was selected. The first shipment of 30 units will arrive with a week and no dental prophylaxis will be provided until these units are avilable.
[Slide #7]
The document also includes considerations for the extended use of PPE for those facing PPE critical shortages. Reprocessing is not advised for surgical masks or respirators. However, there have been some processes for which respirators have been reprocessed successfully through vapor of hydrogen peroxide and UV disinfection, keeping in mind each of these measures carries significant risks and limitations. They should only be considered as a last resort when all other strategies for rational and appropriate use and procurement of PPE have been exhausted.
[Slide #16]
The document also outlines how to wear a mask properly. First, ensure hand hygiene is performed Transcription OpenWHO: MOOC_COVID-19_IPC_Module3 5 before touching the mask. Place the mask carefully on your face ensuring it covers the mouth, nose and chin and tie it securely to minimize any gaps between the face and the mask. Avoid touching the mask while wearing it. Replace it as soon as it becomes damp and remove the mask with the appropriate technique: washing your hands before touching the mask, do not touch the front of the mask but untie it from behind the head or the ears. After removal and whenever a mask is used, clean your hands using an alcohol-based hand rub solution or if hands are visibly dirty.
[Slide #22]
The elements of standard precautions are hand hygiene, respiratory etiquette, PPE according to your risk assessment, safe injection practices, sharps management and injury prevention as well as safe handling, cleaning and disinfection of patient care equipment. This also includes environmental cleaning and Transcription OpenWHO: MOOC_COVID-19_IPC_Module3 6 safe handling and cleaning of soil linen as well as waste management.
Screening patients with travel history or with symptoms.
The first line in managing patients who may carry COVID-19, is health screening prior to the patient entering the facility. Performing the health screening questionnaire at the entrance of the clinic is important to exclude patients with travel history to any area where COVID-19 community spread has been documented or the confirmed cases are high, where contact with infected patients is suspected, and regardless of travel history any patient who has symptoms such as gastrointestinal (diarrhea, vomiting) flu like symptoms, muscle aches and pains, productive cough, dry cough, high fever, sense of loss of smell and/or taste, difficulty breathing, or any combination. Some clinics may screen patients via telephone or text messages before they arrive at the clinic and others may screen them at the reception desk. Where the latter is necessary, staff must be protected from exposure. For large clinics such as a dental school, screening outside the entrance is preferred. At this stage, temperature may be measured using a laser thermometer. Any patient who meets any of the characteristics noted (travel, contact and/or symptoms) are to be excluded from entering the clinic and referred to a nearby hospital or their primary care providers. Patients whose status cannot be determined by the screening staff or have pain associated with a dental infection (swelling, abscess, tooth ache) will be given a mask and referred to the health screening clinic inside the dental school which is located inside the entrance. The screening clinic should be located close to the entrance of the clinic and a dentist should interview the patient and decide whether the patient can be treated, perscribe medications, or refer to a nearby hospital or a primary care provider. Patients who have fever related to a potential dental infection and referred to the health screening clinic must wear a level 3 surgical mask, all other patients will be provided with a level 1 or 2 mask to use while they are at the clinic.
Wearing an N95 Respirator
The following guidelines should be followed: -Trim your facial hair before wearing your mask -Wash your hands well before putting on your mask. -To place on your face, cup the mask in one hand and place it over your mouth and nose. -Pull the bottom and top straps over your head, except for those fitted for . -Mold the nose piece around the bridge of your nose. Make sure the mask feels snug and doesn't slip on your face, remembering that you'll also mold it to your face for an even tighter fit. -Make sure the mask fits tightly and has no leaks. To test the fit, do the following: Negative pressure check: Place both hands completely over the mask and inhale sharply. Be careful not to disturb the position of the mask. The mask should pull into your face. If air leaks around your face or eyes, adjust the nosepiece and straps and repeat the positive pressure check. Positive pressure check: Put your hands over the mask and breathe out sharply. If your mask has an exhalation valve be sure to cover the exhalation valve when you exhale. No air should leak out of the mask if it fits properly. If air leaks out, re-adjust the nosepiece and straps and repeat the negative pressure check.
[Slide #11]
The guidance was updated to incorporate new research findings and to provide more practical advice to decision makers. The main changes relate to the use of masks by health workers and specifics on non-medical masks for the general public in areas of community transmission. This means that we recommend health workers to continuously wear masks throughout their shifts in clinical areas. For the general public, we recommend they only wear masks in communities where widespread transmission of COVID-19 exists and physical distancing cannot be maintained. The new guidance also outlines the ideal features of a fabric mask.
[Slide #2]
The learning objectives for this module are that you should be able to describe IPC standard precautions and additional transmission-based precautions that are generally recommended in health care facilities; and then describe source control, administrative controls, and environmental and engineering controls; you should be able to describe the WHO recommended IPC measures for healthcare facilities. First, I will outline the IPC technical guidance documents that have been developed for COVID-19.
HANDWASHING
Wet hands with water. Apply soap. Rub hands together for at least 15 seconds, covering all surfaces, focusing on fingertips and fingernails. Rinse under running water and dry with disposable towel. Use the towel to turn off the faucet.
This course will review key concepts of both hand hygiene and Standard Precautions. Topics include:
What are Standard Precautions? Why is hand hygiene important? Why are Standard Precautions important? What are some other concerns surrounding Standard Precautions?
[Slide #15]
The new research findings outlined in the document outline the type of materials that should be chosen when making your own fabric mask, keeping in mind the filtration efficiency and breathability of the layers of materials. The number of layers should be a minimum of 2 but ideally 3. There should be a combination of material or fabric used. Choose water-absorbing or hydrophilic materials or fabrics for the internal layers to readily absorb droplets. Combined with an external synthetic material that does not easily absorb liquid, also known as hydrophobic, for the outer layer. The inside layer should ideally be a filter. More material examples are outlined in the document. It also outlines the mask shape, the coating of fabric and mask maintenance, keeping in mind a mask should only be used by one person. They should be changed if soiled or wet. And non-medical masks should be washed frequently and handled carefully so as not to contaminate other items. They should ideally be kept in a plastic resealable bag. Clothing fabrics used to make masks should be checked for the highest permitted washing temperature which is indicated on the clothing label. Non-woven polypropylene spun bond may be washed at high temperatures up to 140 degrees Celsius and the combination of non-woven spun bond and cotton can tolerate high temperatures. So, masks made of these combinations may be steamed or boiled ideally every day after a day of use.
[Slide #28]
The second element I had mentioned earlier was respiratory hygiene. Why is respiratory hygiene or cough etiquette so important in times of outbreaks such as the one for COVID or any other respiratory outbreak? Good respiratory hygiene or cough etiquette can significantly reduce the spread of microorganisms or germs that cause respiratory infections like the cold, flu or COVID.
Lebvel 3 masks instead of N95?
The size of a single COVID-19 virus is 70-90 nm, but the virus does not exist individually but in droplets/aerosols > 0.3 um which can be efficiently trapped by level 2 or 3 masks. We recommend the use of a face shield with level 3 masks for all dental procedures. However, if an operator is using loupes and light and cannot use shields, then an N95 masks (fitted) should be used. In keeping with CDC and ADA Guidelines, N95 masks should be used in the oral surgery clinic and in the new AGDP clinic on the third floor. N95 masks should be used whenever there are several patients being treated using a hand piece or ultrasonic instruments in one clinic (graduate endodontics or graduate periodontics). The evidence supports the equivalency of surgical masks (Level 3) and N95 in clinical settings (Attachments 6 to 8) https://www.crosstex.com/sites/default/files/public/educational-resources/products-literature/guide20to20face20mask20selection20and20use20-202017.pdf
[Slide #26]
There are many posters available on the WHO website on how to hand rub using alcohol-based hand rub or how to hand wash using water and soap. Please make note to use the appropriate product and the technique. So, we know the alcohol-based hand rub is preferable if the hands are not visibly soiled. We recommend rubbing the hands for 20 to 30 seconds with this. However, if your hands are soiled, we recommend water and soap and a single use towel when visibly dirty or contaminated with material. We recommend washing with water and soap for 40 to 60 seconds.
[Slide #3]
There have been several IPC technical guidance documents posted on our website since the beginning of the outbreak. The main document: "IPC during health care when COVID-19 is suspected" outlines the IPC measures that should be in place when caring for a suspect or confirmed case of COVID-19. The "rational use of PPE and considerations during PPE shortages" is a document that outlines what facilities should do to prepare for a shortage of stock supply such as masks as we have currently experienced in this outbreak. Next, there is an advice piece on the use of masks in the community, during home care and in healthcare settings. WHO regularly monitors all emerging evidence about these critical topics and will provide updates as more information becomes available.
[Slide #27]
These are some alternative posters that show how to perform handrub or how to handwash.
[Slide #31]
These are some of the PPE or personal protective equipment items that are for use in healthcare settings. The first is a gown which should be used to protect the body and the clothing of the healthcare worker. The medical mask covers the nose and mouth and acts as protection for the healthcare worker. An alternative to this is the respirator also known as N95, FFP2 or FFP3. This is used when airborne precautions are recommended. The eye protection consists either a face shield or goggles. These are usually used in combination with a mask or respirator. The gloves should be used to protect the hands and prevent transmission of infectious material during health care. Remember to combine these with hand hygiene at all times.
Disinfection of the dental operatory:
Wearing gown, mask, protective eyewear, and NEW nitrile utility gloves, complete the following; 1) Flush all water lines (handpiece and air/water) for at least 30 seconds. 2) Remove all barriers, place in infectious waste receptacle. 3) Clean and disinfect all clinical contact surfaces. Use designated surface disinfectant spray on counter-tops, bracket tables, cabinet doors. Wipe down the operatory chair with the available soap solution. Utilize the following method: Spray → Wipe (clean) → Spray →Wait (based on manufacturer's recommendation) → Wipe 3) Discard all disposable items in the infectious waste receptacles. Make sure that infectious waste container lid is closed after use. 4) Discard needles, anesthetic carpules, burs, endodontic files, and other sharps into designate puncture-resistant containers, marked "biohazard" located within the operatory. 6) Place instruments neatly in the cassettes, with tips pointed downward, and secure the lid. Disinfect all patient contaminated items - surfaces of cavitron, curing light, shade guides, denture tooth selection books, surveyors, etc. Place in a plastic bin to return to the soiled dispensary. Reusable facial protective equipment (face shields), they must be cleaned with soap and water or approved disinfectant. 7) Remove PPE and utility gloves using doffing protocols. Discard in in the regulated infectious waste container. Wash hands using soap and water for minimal of 20 seconds. Follow TUKSoD protocol (based on CDC and OSHA regulations) in the event of suspected unintentional exposure to infectious secretions. Referrals for COVID-19 testing should be given detailed instruction on where to go and when for testing, how to justify the need for testing and how to contact the dental clinic to report testing. If a test is positive, the clinic needs to report the exposure to all patients treated after the infected patient.
Infection control standard for providing aerosol generating dental procedures (AGDP)
These protocols will follow "transmission based precautions". 1. Screening process which begins 14 days prior to a scheduled appointment or at the entry way of the dental clinic for walk-in emergency patients. (Attachment #9). All patients will be screened at entrance and triaged for further assessment by a dentist or referred to a health care facility. To reduce the chance of disseminating droplets, patiets will be provided with a level 1 mask to enter the dental school. Patients will be required to wear the masks, for this period, while they are the school. As the pandemic progresses, it will be important, when addressing individuals who were infected with COVID-19 if they are ready to discontinue home isolation. CDC suggests two approaches: time since illness onset and time since recovery (recent evidence is minmum of 25 days). Both are non-test based. The other is test-based strategy. https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.html 2. Upon arrival patients, the patient will have their temperature taken and be asked the COVID-19 screening questions. 3. While scheduling should occur to manage crowds, if a patient arrives and the waiting area doesn't allow for adequate social distancing, the patient is to be asked to wait in their personal vehicle or outside (distancing from one another) where they can be contacted by cellphone. 4. Once patient is cleared through the screening protocol and assigned to the appropriate process, their care will commence as follows:
[Slide #23]
This diagram represents the chain of transmission. An infection occurs when a microorganism enters the body and increases in number and damages tissues in the body. For any infection to spread, all steps in the chain must occur. The key to stopping the spread of infection is to break at least one link within the chain.
[Slide #29]
This includes turning your head away from others when coughing or sneezing, covering the nose and mouth with a tissue and discarding that tissue immediately, or coughing or sneezing into your elbow if no tissue is available and then we recommend hand hygiene, cleaning your hands with soap and water or alcoholbased products.
[Slide #21]
This is the basic level of IPC precautions to be used for all patients at all times, not just in times of outbreak, the minimum prevention measures that apply at all times to all patients, regardless of suspected or confirmed status of the patient. This risk assessment that should be performed by healthcare workers is critical for all activities. This means assessing each healthcare activity and determining the personal protective equipment that is needed for adequate protection, regardless of their isolation status.
[Slide #2]
This module describes the COVID-19 virus or SARS-CoV-2, the modes of transmission and case definition. Let's begin!
[Slide #8]
This slide outlines the strategies to minimize the need for PPE. These include considering telemedicine to evaluate suspect cases minimizing the need for them to visit healthcare facilities for evaluation in person; implementing physical barriers such as glass or plastic windows where patients may first present such as in triage areas or the emergency registration desk or a pharmacy window; limit the number of health care workers entering COVID-19 patient rooms and plan ahead what activities will be performed at the bedside to avoid multiple entries and exits; consider bundling activities and do not allow visitors where COVID-19 patients are isolated or restrict their number and time allowed spent there.
[Slide #5]
Thus far, we know that the primary modes of transmission of COVID-19 are either through respiratory droplets which can be generated when an infected person speaks, coughs or sneezes. Any person who is in close contact with someone who has respiratory symptoms is at risk of having his or her mouth or nose or eyes exposed to potentially infective respiratory droplets. Or through contact which can be either direct contact with infected people or indirect contact with surfaces or objects in the immediate environment. Droplets from the mouth may land on surfaces and the virus could remain viable for hours or days.
Social distancing
To maintain the required social distancing requirements, all didactic lectures and meetings, including orientations of new students and residents, will be conducted online until the Philadelphia is designated as "green" zone or as dictated by Temple University . The space allocation in the preclinic dental simulation laboratory will follow the recommendations of Temple University (48 seats without sneez guards and 70 with sneeze guards). The clinics have been designated as either areosol generatiomng or non-aerosol generationgn with more stringent PPE requirememnt for areosol areas. The distance between clinical cubicles is 7 ft and the cubicles are separated by at least a 5 ft 8 inch height cabinets. All students, faculty, and staff, and guests, will wear level 2 or higher masks inside the school and will be provided with a santizer bottle that can be refilled at the school with no charge. All students in the preclinical lab will ear a level 3 mask and face shield.
How long should you rub your hands together when applying an alcohol-based hand rub?
Until your hands are dry
[Slide #25]
WHO promotes the five moments of hand hygiene. Moment number one is before you are entering the patient's environment and touching a patient you should be doing hand hygiene: this involves either alcohol-based hand rub or water and soap. Before preparing a clean or aseptic procedure, you should be practicing hand hygiene again. And after bodily fluid exposure or risk, you should be practicing hand hygiene. This means if you have soiled gloves or soiled hands, you should be taking them off and practicing hand hygiene with water and soap. After touching a patient, you should also be performing hand hygiene. And after leaving the patient's environment or surroundings, you should again be performing hand hygiene. This means that after taking off your PPE, you should be performing hand hygiene as the last step.
Cleaning refers to the first step required to physically remove contamination by foreign material. It will also remove organic materials such as blood, secretions, excretions and microorganisms to prepare a medical device for disinfection or sterilization. Disinfecting refers to the process to reduce the number of viable microorganisms to a less harmful level. This process may not inactivate bacterial spores prions and some viruses and thus sterilization is needed. Sterilization is a validated process used to render an object free from viable microorganisms as mentioned above. These include viruses bacterial spores but not prions.
What are some of the principles of cleaning? Cleaning is the physical removal of foreign material and organic material. It physically removes rather than kills microorganisms. It is accomplished with water, detergents and mechanical action. The basic principles of cleaning and disinfecting apply to all patient care areas. So be sure to always clean the patient care equipment between each use and where possible dedicate cleaning supplies in higher risk areas. These are isolation rooms, delivery rooms and operating rooms among others. The cleaning supplies for isolation should be kept and only used in the isolation rooms.
[Slide #4]
What we currently know about COVID-19 is that the incubation period ranges from 1 to 14 days with a median of about 5 to 6 days. These estimates will be refined as more data becomes available. More information is also needed to determine to what extent transmission can occur from asymptomatic individuals, those who have never developed symptoms or through pre-symptomatic individuals, those who are still in the incubation period before they fully develop symptoms. Currently, there is no preventive vaccine although one is hopefully due to arrive in the next year.
SO, I NEED TO IMPROVE. WHEN SHOULD I PRACTICE HAND HYGIENE?
Whenever hands are visibly dirty or contaminated. Before:having contact with patientsputting on glovesinserting any invasive devicemanipulating an invasive device After:having contact with a patient's skinhaving contact with bodily fluids or excretions, non-intact skin, wound dressings, contaminated itemshaving contact with inanimate objects near a patientremoving gloves
Recommendations for When to Discard an N95 Respirator
While there is no standard determination on how many times an N95 respirator can be reused, the following are guidelines regarding when to discard a respirator are: Discard N95 respirators if they have been exposed to aerosols. Note: During aerosol generating procedures, a full-face shield which extends below the chin and covers the side of the face to just infront of the ears should protect the respirator. Also, some advocate an additional protection of the N95 by placing a surgical mask over the N95. This is ok, but not required and it does not negate the use of a face shield. Discard if contaminated with blood, respiratory, nasal or other bodily fluid. Discard the respirator if it is wet or dirty on the inside, if it is deformed, or if the filter is torn. A deformed mask may not fit properly. Discard if the inside of the mask has been inadvertently touched when donning or doffing for reuse.
Youtube
Youtube Remove personal clothing and items Visually inspect PPE prior to donning Don protective booties (optional) Perform hand hygiene Don inner glove Don fluid-resistant gowns (ANSI/AAMI level 3) Don facial protection Don hair cover (optional) Don outer gloves/single pair of respiratory HCID Don full face shield or PAPR Verify See pt Inspect Disinfect and remove outer gloves Inspect and disinfect inner gloves (or single pair) Remove full face shield Remove PAPR Disinfect inner gloves Remove hair cover (if worn) Disinfect inner gloves Remove gown Disinfect inner gloves Remove protective booties (if worn) Disinfect and remove inner gloves Perform hand hygiene Don a new pair of gloves Remove facial protection Disinfect and remove gloves Perform hand hygiene inspect
ALCOHOL-BASED HAND RUBS ARE MORE EFFECTIVE IN KILLING BACTERIA THAN SOAP AND WATER.
regular soap < antimicrobial soap < alcohol based hand rub (foam or gel)
DOFFING (TAKING OFF) PPE AT TEMPLE UNIVERSITY MAURICE H KORNBERG SCHOOL OF DENTISTRY
slowly remove ppe in the following sequence to prevent contaminating your clothing, skin, or mucous membranes with potentially infecious materials. any ppe contaminated with blood or body fluids must be placed in the red, biohazard waste bag. otherwise it may be placed in the regular trash bin - following the removal of your gloves, perform hand hygiene (washing or sanitizing) prior to each step in doffing process 1. Gloves 2. Gown 3. Show Covers 4. Loupes (or other eye protection) and face shield 5. hair cover 6. face mask or respirator 7. staff, residents, and/or students may now exit patient area
Hand hygiene
washing hands with either plain or antiseptic soap and water and using alcohol-based hand rubs
Don shoe covers
ü All areas of the shoe covered Avoid touching floor
Face mask or respirator
ü DO NOT touch front of face mask/respirator ü Tilt head forward ü Grasp face shield strap, pull gently over head and allow to fall forward Grasp sides/arms of loupes or eye protection
Gown
ü DO NOT touch front of gown ü Unfasten gown ties ü Pull gown away from neck and shoulders, touching inside of gown only ü Turn gown inside out and roll into bundle Discard in appropriate waste
Loupes (or other eye protection) and face shield
ü DO NOT touch outside of loupes/face shield ü Remove face shield by lifting head band ü Remove loupes (other eye protection) from earpieces (arms) Discard in appropriate waste
Don hair cover
ü Ensure coverage of entire scalp and hair
Final inspection
ü Extend arms and verify integrity of PPE ü Bend at waist ü Squat and return to standing position Slowly turn in circle for final inspection
Don surgical gown
ü Full coverage neck-knees, arms-wrist, wrap around back ü Fasten at the neck and waist
Prepare to don PPE
ü Hydrate and tend to personal needs ü Remove jewelry than can compromise PPE Secure long hair
Inspect PPE
ü Inspect PPE for tears and proper sizing
Don loupes (or other eye protection) and face shield
ü Place over eyes and face Adjust face shield to fit securely
Don face mask or respirator
ü Secure ties/straps on crown of head and base of neck Perform user seal check
Collect PPE in appropriate size
ü Surgical gown ü Bonnet ü Shoe covers ü N95 respirator ü Face Shield ü Goggles/loupes w/ side shield ü Nitrile gloves
Shoe covers
ü Touch highest part of shoe cover behind ankle only ü Discard in appropriate waste
Gloves
ü Use gloved hand, grasp palm area of other gloved hand and peel off first glove ü Hold glove in remaining gloved hand ü Slide finger under wrist of remaining glove and peel off second glove over first Discard in appropriate waste
6. Face Mask or Respirator
• Front of face mask/respirator is contaminated — DO NOT TOUCH! • Grasp the bottom tie or strap of the mask/respirator,then the one at the top, and remove without touching the front
3. Gown
• Fully cover torso from neck to knees, arms to end of wrists, and wrap around the back • Fasten behind neck and waist
2. Gown
• Gown front and sleeves are contaminated — DO NOT TOUCH! • Unfasten gown ties, taking care that sleeves don't contact any unprotected area of your body when reaching for ties• Pull gown away from neck and shoulders, touching inside of gown only• Turn gown inside out• Fold or roll into a bundle
1. Gloves
• Outside of gloves are contaminated• Using a gloved hand, grasp the palm area of the other gloved hand and peel off first glove• Hold removed glove in the remaining gloved hand • Slide fingers of ungloved hand under remaining glove at wrist and peel off second glove over first glove
4. Loupes (or other eye protection) and Face Shield
• Outside of loupes and face shields are contaminated — DO NOT TOUCH! • Remove loupes (or other eye protection) and face shield from the back by earpieces and lifting head band • If the item is reusable, clean according to the manufacturer's direction and store in a designated area
6. Loupes (or other eye protection) and Face Shield
• Place over eyes and face, and adjust to fit
2. Shoe Covers
• Pull covers over shoes• Make sure that all areas of the shoes are covered• Try not to touch the floor or possibly contaminated areas with your hands while putting the shoe covers on. If you do, disinfect your hands before donning gown.
5. Hair Cover
• Remove from behind the head
4. Face Mask or Respirator
• Ties or straps should be secured on crown ofhead (top tie/strap) and base of neck (bottom tie/strap) • Perform a user seal check each time you put on a respirator
3. Shoe Covers
• Touch the highest part of shoe cover behind ankle only when removing from each foot
1. Perform Hand Hygiene
• Wash hands or use an alcohol-based hand sanitizer
