Annual infection control & safety check-up: an OSAP continuing education resource: is your office program up to date?

Dental offices and institutions are presented with an array of regulations, recommendations, and guidelines that make the practice of dentistry safer for patients and the professionals who treat them. The Occupational Safety and Health Administration (OSHA), Centers for Disease Control and Prevention (CDC), American Dental Association (ADA), and OSAP have outlined procedures that protect occupational health and enhance patient safety.

To help dental workers meet compliance challenges posed by guidelines and regulations from multiple sources, OSAP has compiled a checklist of procedures that reduce the risk of disease transmission in dentistry. Most components of OSHA's safety and health laws require, at minimum, annual review and updating of safety programs and procedures. If your practice has not yet examined its written programs, training schedules, and records to ensure they are up to date, it may be prudent to make some time for a policy and procedural "check-up."

Due for release in late 2003, the CDC is finalizing its updated infection control recommendations for dentistry. Additions to this checklist will be published in a subsequent special edition of OSAP's Infection Control In Practice.

How does your practice score in OSAP's annual infection control and safety check-up?

Exposure Control Plan

* Does the practice have a written exposure control plan covering:

* OSHA Universal Precautions: treating all patients as if they are infected with a transmissible bloodborne disease

* Standard Precautions: universal precautions plus transmission-based precautions (detailed at www.cdc.gov/ncidod/hip/isolat/isopart2.htm) applied for patients infected with pathogens that can be transmitted by airborne (e.g., tuberculosis) or droplet routes (e.g., severe acute respiratory syndrome, SARS) or by direct patient contact

* Exposure Determination: list of the jobs that typically place employees at risk of occupational exposure to bloodborne pathogens 

* Engineering Controls: devices or technologies used in the practice that remove or isolate a workplace hazard

* Work Practice Controls: methods of performing tasks that remove or isolate a workplace hazard

* Personal Protective Equipment: gloves, masks, gowns, and eyewear to protect against hazards

* Management of Exposure Incidents: immediate reporting of occupational exposures to blood or other potentially infectious materials and referral to a qualified medical provider for evaluation and follow-up care

* Recordkeeping: Standard Operating Procedures for the practice; employee medical records; training records; and other required documentation

* Methods of Compliance: a practice-specific, step-by-step description of tasks as they should be performed to reduce the risk of occupational injury to the greatest extent possible (also referred to as Standard Operating Procedures)

* Is the plan reviewed and updated at least annually?

Date of last review/update:

Hand Hygiene

* Do staff members wash their hands when they are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids?

* When hands are not visibly soiled, do staff members decontaminate hands (via handwash or alcohol-based hand rub):

* before donning gloves

* after contact with a patient's intact skin (e.g., after taking a blood pressure reading)

* after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings

* after contact with inanimate objects in the immediate vicinity of the patient

* after removing gloves

* Before surgery, are nails, hands, and forearms thoroughly cleaned with an antimicrobial surgical scrub for the contact time recommended by the scrub manufacturer? Alternatively, is surgical hand antisepsis performed using an alcohol-based hand rub with persistent activity?

* Are hands always thoroughly rinsed and dried after handwashing? Failure to thoroughly rinse and dry hands can cause skin irritation.

Personal Protection

* Is proper personal protective equipment (gloves, masks, eyewear, and apparel) provided to at-risk employees in the appropriate sizes and materials? Some barriers can cause allergic reactions in susceptible individuals.

* Is all personal protective equipment provided at no cost to at risk employees?

* Are gloves, surgical masks, eyewear, and protective apparel (i.e., garments worn over the clinic uniform or street clothes) donned by patient care staff during spatter-generating procedures?

* Are the same types of personal protective equipment donned for all patients undergoing the same procedure, regardless of their medical history?

* Is laundering protective apparel managed by the practice (rather than the responsibility of the employee)?

* Have all employees at risk of occupational exposure to blood been vaccinated against the hepatitis B virus?

If not:

* Have the risks of occupational exposure and the benefits of the hepatitis B vaccine been fully explained to the employees?

* Has the hepatitis B vaccine been offered, at no charge, to all employees at risk of occupational exposure, with recommended follow-up blood tests to confirm immune status?

* For employees informed of their risks and the benefits of immunization who have declined the vaccine:

* Has the employee signed the designated "Hepatitis B Vaccination Declination Waiver Form" (posted at www.osha.gov/pls/oshaweb/ owadisp.show_document? p_table=STANDARDS&p_i d--10052)?

* Has the employee been informed that he or she may accept the vaccine, at no charge, at a later date?

Sharps Safety

* Have sharps with engineered sharps injury protection (such as self-sheathing needles, safety scalpels and needles, and needleless IV catheters or ports) been considered for use in the practice?

* Have nonmanagerial employees been allowed to assess available sharps injury prevention devices for their value in reducing occupational risks in the practice?

* Have the sharps safety device evaluation and employee input into the evaluation process been documented?

* Are contaminated sharps disposed of in leakproof, puncture-resistant containers that are color-coded red or identified by the biohazard symbol?

* Are sharps containers located close to the point of use (i.e., in each operatory)?

* Do they have a lid that can be securely closed to prevent spilling if dropped?

* Are sharps containers disposed of as soon as contents reach the fill line? Never overfill sharps containers.

* If needles are recapped or resheathed, do employees use at least one of the following options:

* Needles with an engineered safety feature (such as self-sheathing needles)?

* Recapping/resheathing device that allows one-handed recapping?

* One-handed scoop technique?

Medical Emergencies

* Is at least one person per shift trained in cardiopulmonary resuscitation?

* In the event of occupational exposures to blood or other potentially infectious materials, are staff members aware of the need to immediately apply first aid, then report the exposure to the designated person in the practice?

* In case of occupational exposures, does the employer or designated infection control program manager fill out an exposure incident report that includes:

* date and time of exposure;

* route(s) of exposure;

* circumstances under which the exposure occurred;

* type and amount of fluid or material;

* severity of exposure (for per cutaneous injuries, depth of injury and whether fluid was injected; for skin or mucous membrane exposures, estimated volume of material and description of skin condition);

* name of the source patient (if known and permitted by law);

* source patient's hepatitis B vaccination and response status, if known;

* for HIV-positive source individuals, information on the stage of disease, history of antiretroviral therapy, viral load, and antiretroviral resistance, if available;

* if a sharp device was involved, the type and brand of device and how and when, in the course of its handling, the exposure occurred?

* Are first aid supplies and equipment routinely checked for working order and expiration dates?

Date of last inspection: --

Employee initials: --

* Have arrangements been made with a local emergency healthcare facility to handle medical emergencies(such as patient emergencies, allergic reactions, and postexposure evaluation and management)?

Name, address, and phone number of facility: --

Instrument Processing

* If they cannot be immediately cleaned, are instruments placed in a presoak (such as water or detergent) to prevent debris from drying on surfaces?

* Are instruments routinely cleaned in an ultrasonic cleaner or instrument washer?

* When instruments must be handscrubbed, is a long-handled brush used and is scrubbing performed below the waterline to minimize splashing?

* Are puncture-resistant utility gloves worn when handling contaminated sharps? For example, when handscrubbing instruments, loading the ultrasonic cleaning basket or instrument washer, drying and packaging instruments.

* Are face masks, protective eyewear, and protective apparel worn during instrument cleaning procedures that create splash or spatter? For example, when handscrubbing instruments or loading the ultrasonic cleaning basket.

* Are instruments packaged prior to sterilization? This protects them from contamination after the sterilizer cycle.

* Is sterilization packaging compatible with the method of heat sterilization?

* Is a color-change chemical indicator used inside and in the center of each pack? Color-change indicators distinguish processed instrument packs from unprocessed packages and may be helpful in identifying gross sterilizer malfunction.

* Does the practice use spore tests (biologic indicators) to periodically monitor sterilizer efficacy? (ADA, CDC, and OSAP recommend weekly monitoring.)

* Is the spore test appropriate for the mode of sterilization and carried out according to the manufacturer's instructions?

* Are sterile packs stored in a way that maintains sterility of the instruments?

Surface Management

* Are clinical contact surfaces disinfected or barrier-protected for each patient?

* Are surfaces thoroughly cleaned before they are disinfected or barrier-protected?

* Is the surface disinfectant:

* registered with the Environmental Protection Agency (EPA);

* classified as a hospital disinfectant; and

* tuberculocidal?

* Is appropriate personal protective equipment--gloves, mask, and eyewear--worn when cleaning and disinfecting operatory surfaces?

* Are contaminated surface barriers replaced between patients?

Housekeeping

* Does the practice have a written schedule for cleaning and decontaminating the work site?

* Is the practice maintained in a clean and sanitary condition?

Waste Management

* Does the practice have a written waste management plan consistent with state/local guidelines?

Signs & General Safety

* Is all required OSHA signage displayed?

* OSHA 2203: Poster of employee rights; or

* OSHA 3165: Plain-language poster

* Is the biohazard symbol (or color-coding) used to clearly warn of infectious hazards?

* Does the practice have at least two clearly marked, unobstructed exits?

* Are compressed gas cylinders secured out of the way of solid flammable materials and clear of all exits?

* Is local exhaust maintained in areas where grinding, dry polishing, or buffing occurs, or if exposure exceeds permissible limits, in areas where chemicals such as glutaraldehyde or formaldehyde are used?

Hazard Communication

* Does the practice maintain a list of all chemicals it uses?

* Does the practice have written instructions for the safe use of each chemical?

* Are Material Safety Data Sheets (MSDSs) on file for each chemical used in the practice?

* Can employees read and interpret a Material Safety Data Sheet (MSDS)?

* Is such information included or referenced in a written, practice-specific Hazard Communication Program?

* Do employees know the location of the practice's written Hazard Communication Program, the MSDSs, and chemical inventory?

* Do all staff members understand the color-coding and symbols used to identify biologic, chemical, and other hazards in the practice?

* Are all containers labeled at the point of use with:

* the original product label; or,

* if a secondary container is used,

* product name,

* chemical identity,

* appropriate hazard warnings,

* manufacturer name and address (optional)?

* Is the practice setting's written Hazard Communication Program reviewed/updated:

* at least annually?

* whenever a new chemical is introduced in the practice?

* For air compressor drains and traps, is the drain valve on the air receiver open? Is the receiver completely drained frequently to prevent excessive accumulation of liquid?

* Are safety shields in place to protect against projectile debris?

* Are all electrical devices with a three-prong plug grounded?

* Are all electrical outlets within six feet of a sink or other plumbing on a ground fault interruptor (GFI) circuit?

* Does the practice have a working eyewash station that all employees know how to use?

Training

* Are all new employees trained at the time of initial assignment in:

* Standard (universal) precautions?

* Standard Operating Procedures for tasks in the practice (such as instrument processing, waste management, hazard communication, etc?

* Exposure control, including:

* Engineering controls (for example, the use of automated instrument cleaners, sterilization equipment, sharps safety devices)?

* Work practice controls (for example, using an instrument instead of fingers to retract tissue, passing instruments with sharp ends pointed away from all persons, recapping needles using a one-handed scoop technique)?

* Personal protective equipment (appropriate use of gloves, masks, eyewear, protective apparel, and utility gloves)?

* Postexposure procedures (for reporting, managing, and referring percutaneous and mucous membrane exposures in the practice)

* Hazard communication (chemical hazards in the workplace and how they are communicated in the office)

* Is training conducted annually for all employees to update and ensure continued compliance with standard procedures?

Recordkeeping

* Does the practice maintain the following records for the necessary duration?

* Employee health records for those at risk of occupational exposure--the term of employment plus 30 years

* Training records--three years (including who conducted the training, names of employees who attended, and the instructor's qualifications)

* Emergency procedures plan, covering evacuation and other procedures in case of fire or other emergency (required for offices with more than ten employees)

* Chemical safety records:

* Lists of chemical inventory for each year--30 years

* MSDS file--30 years (including sheets for chemicals no longer used)

* Any unanswered letters to manufacturers sent to request MSDSs

* Waste management records--as required by state and local law

* Manifests for regulated waste hauling (including a description of the waste; total quantity shipped; type of container used to ship; transporter name, address, and state permit or ID number; quantity and category of waste transported; shipping date; signature of representative accepting the waste for shipment)

* If applicable, records of waste treated onsite to render it noninfectious (including Standard Operating Procedures for waste sterilization, biologic monitoring logs for each infectious waste load, and equipment maintenance records)

* Other helpful records such as:

* Housekeeping schedules (to verify that the office equipment and environment are appropriately cleaned and maintained on a regular basis)

* Sterilization monitoring logs (documenting date and time of sterilization)

* High-level immersion disinfection log (to confirm that chemicals are properly mixed, maintained, and discarded at the proper interval; includes date and time of chemical replenishment and name of person performing the task)

* Biologic monitoring log (recording all relevant data)

* Equipment maintenance and repair log (dates of repair and services, receipts, and service contracts)

* Surface disinfection log (if using concentrate that must be diluted for use, log the dates mixed and the person performing the task)

Dental Water Quality

* At minimum, are waterlines flushed for several minutes each morning? Although flushing can remove suspended organisms, it does not remove biofilm in dental water systems.

* Are lines flushed with air/water for 20 to 30 seconds after use on each patient?

* If recommended by the dental unit manufacturer, has the practice installed and maintained antiretraction valves? Most units don't require antiretraction valves; they are engineered not to retract.

* If the dental unit uses a separate water reservoir system, is it maintained as directed by the manufacturer? Failure to properly maintain a bottled-water system can yield greater contamination than a municipally plumbed dental unit.

* Are sterile irrigating solutions used for all surgical procedures? Because the organisms live within the waterlines, only heat-sterilized/sterile-disposable bulb syringes or sterile water delivery devices should be used to deliver the sterile water.

* Has staff been trained on effective waterline treatment measures and the importance of compliance to minimize risks to equipment and personnel?

* If a sterile water system or other device marketed to improve dental water quality is used, has the system or device been cleared for market--510(k)--by the Food and Drug Administration (FDA)? See www.osap.org/issues/pages/water/wlfda.htm for a list of commercially available chemicals and devices for improving dental water quality.

Note: Water treatment devices FDA-cleared as part of the dental unit will not have a separate 510(k) number.

Preprocedural Mouthrinse

* Are patients provided with an antimicrobial mouthrinse to reduce bacterial counts in the oral cavity and in aerosols created during dental procedures?

-- OSAP

To earn a full hour of CE credit, turn the page.

Practice Tip Keeping it together--instruction manuals and equipment, that is

Each edition of OSAP's Infection Control In Practice includes a tip from an OSAP-member clinician or consultant. This popular column shares practical, successful strategies for streamlining dental infection control procedures in practice.

In the dental setting, we rely on precision equipment, worker know-how, and routine use of specific procedures to ensure safe, quality patient care. In operating and maintaining dental equipment, Dr. Shannon Mills with the Office of the Air Force Surgeon General has a suggestion to make sure that both human and mechanical factors are always on the same page. Literally.

"The manufacturers of every piece of dental equipment in your office have prepared detailed users' guides and operating instructions that, when consistently applied, ensure reliable equipment performance," he says.

"For each piece of dental equipment you have, take the page of standard operating instructions, summarize it in an easy-to-follow procedural checklist, and post it next to the device," he says. Some users' guides even have "quick start" instructions that can be photocopied and posted.

"Having instructions in clear view of the device is a great reminder for workers who use the equipment routinely as well as for those who might use it only occasionally," Dr. Mills explains. The checklists reinforce techniques and procedures introduced during training and encourage compliance every day, every time the equipment is used, he says. Including notes on warning lights and other trouble signs allows problems to be identified and addressed as they arise.

In addition to the posted checklists, it's also a good idea to keep all equipment manuals together in a central place, Dr. Mills notes. He suggests using a three-ring binder.

"Make sure everyone in your practice knows where the binder is kept and encourage them to reference it as needed," he says. "At the front, list each manufacturer's name, technical support phone number, and e-mail address.

"When you need assistance from the company, you have all the contact information at hand."

-- OSAP

Reprinted with permission from Infection Control In Practice, [C] OSAP, 2003. Infection Control In Practice is a trademark of the Organization for Safety and Asepsis Procedures. OSAP assumes no liability for any actions taken based on information herein.

Shannon Mills, DDS, is a member of the OSAP Board of Directors and Editor of OSAP's Infection Control In Practice. Statements expressed are his own and do not reflect official policy of the U.S. Government.