Infection Prevention and Control (IPAC) Guidelines

Transcription

1 Infectin Preventin and Cntrl (IPAC) Guidelines Published: December 2018

2 Published: December , Cllege f Dental Hygienists f Ontari

3 Table f Cntents Intrductin... 4 Prfessinal and Regulatry Cnsideratins... 5 Written Plicies and Prcedures... 6 Occupatinal Health and Safety Requirements and Wrkplace Hazardus Infrmatin System (WHMIS)... 8 Human Rights Transmissin f Micrrganisms Oral Health Care Prvider and Client Safety Rutine Practices Risk Assessment Hand Hygiene Alchl-Based Hand Rub vs Sap and Water Effective Hand Hygiene Techniques Barriers t Effective Hand Hygiene Persnal Prtective Equipment (PPE) General Cnsideratins Prtective Cvering Masks Prtective Eyewear Glves Envirnmental Cntrls Handling f Sharps and Expsure Preventin Expsure Management Administrative Cntrls Educatin and Training Immunizatin Illness and Wrk Restrictins Additinal Precautins Reprcessing Classificatin f Client Care Equipment Single-Use Items/Devices Reprcessing Area

4 Cleaning Reusable Dental Instruments/Devices Manual Cleaning Ultrasnic Cleaner Washer-Disinfectrs Disinfectin Lw t Intermediate Level High Level (Cld Sak) Preparing and Packaging f Reusable Dental Instruments/Devices Sterilizatin f Reusable Dental Instruments/Devices Steam Sterilizatin Unacceptable Methds f Sterilizatin Flash Sterilizatin Mnitring Determining the Effectiveness f the Steam Sterilizatin Prcess Prcess Challenge Devices (PCD) Air Remval/Bwie-Dick PCD Test Pack Bilgical Indicatr PCD Test Pack Bilgical Indicatr PCD Failure Chemical Indicatr PCD Test Pack CI, CI PCD and/r Physical Parameters Failures Lgging the Sterilizatin Prcess Dcumenting a Recall Incident Qualifying and Requalifying Yur Sterilizer Strage f Reprcessed Dental Instruments / Single-Use Devices Envirnmental Cleaning Public Cntact Surfaces Clinical Cntact Surfaces Barriers Waste Management Bimedical Waste General Office Waste Dispsal f Teeth Mercury-Cntaining Waste Prtcl

5 Special Cnsideratins Dental Unit Waterlines Dental Handpieces and Other Devices Bil-Water Advisry Saliva Ejectrs and Suctin Lines Radigraphy Equipment Film Digital Radigraphy Intraral Cameras Lasers Sharpening Stnes Injectable Medicatins, Vials and Slutins Dental Labratry Sending Items t a Cmmercial Lab Receiving Items frm a Cmmercial Lab Sending Items Out fr Repair and/r Maintenance Resurces Glssary

6 Intrductin Oral health care wrkers (OHCW) have an bligatin t their clients t establish and maintain practice envirnments that have rganizatinal structures, plicies and resurces in place that are cnsistent with legal, prfessinal and ethical respnsibilities that prmte safety, respect, and supprt fr all persns within the practice setting. An OHCW meets this practice standard by: ensuring that all legislative requirements are met ensuring written plicies and prtcls are in place fr the practice envirnment, such as wrkplace health and safety, infectin preventin and cntrl, managing hazardus wastes, and respecting human rights maintaining facilities, equipment, supplies and technlgy sufficient t prvide a full scpe f practice safely and effectively securing and maintaining apprpriate service schedules and service recrds ensuring that current scientifically accepted infectin preventin and cntrl practices are in place. 4

7 Prfessinal and Regulatry Cnsideratins These guidelines cntain infectin preventin and cntrl (IPAC) best practice recmmendatins which must be fllwed by all dental hygienists practising in Ontari while prviding client care. The CDHO s infectin preventin and cntrl guidelines are cnsistent with guidance dcuments frm Public Health Ontari (PHO), the Public Health Agency f Canada (PHAC), the Prvincial Infectius Disease Advisry Cmmittee (PIDAC) and the Canadian Standards Assciatin (CSA). This dcument will be used by the Cllege f Dental Hygienists f Ontari and/r may be used by thers in determining whether apprpriate standards f practice and prfessinal respnsibilities have been implemented and maintained. The CDHO recgnizes that this aspect f practice is cnstantly evlving, therefre, this dcument presents best practices at the time f publicatin and will be amended as new infrmatin becmes available. 5

8 Written Plicies and Prcedures Accrding t PIDAC, CSA and PHAC, all ral health care wrkers are required t establish and dcument practice-specific written plicies and prcedures that are based n current recgnized standards and best practices. A plicy and prcedure manual fr up-t-date IPAC prtcls must be fllwed by all OHCWs, reviewed at least annually r mre frequently as new infrmatin becmes available, and must address the fllwing: requirements fr educatin and training f all OHCWs, including a prcess fr cntinual imprvement, and dcumentatin f quality imprvement IPAC gals immunizatin and vaccinatin status f OHCWs rutine practices such as hand hygiene risk assessment apprpriate selectin f persnal prtective equipment all aspects f the reprcessing f dental hygiene instruments/devices including the emplyment f single-use items when dental equipment/devices cannt be cleaned and reprcessed accrding t the recmmended standards the remval f faulty instruments/devices until repaired r replaced the dcumentatin f maintenance and repair f all cleaning and sterilizatin equipment kept fr 10 years as indicated in the CDHO Recrds Regulatin quality mnitring and dcumentatin f the reprcessing prcedure including bilgical indicatr tests, chemical indicatr tests, and physical parameters. (All test results must be lgged, evaluated after each cycle, signed by the persn respnsible, and kept fr 10 years as per the CDHO Recrds Regulatin.) infrmatin t be recrded n instrument packages which must include a sterilizer number, lad number and date f sterilizatin, lad cntents, and persn wh assembled the package a recall f imprperly reprcessed equipment that includes ntificatin f the apprpriate authrities, assessment f client risk, and determining if additinal ntificatin f client, ther facilities, and/r regulatry bdies (e.g. public health unit, regulatry cllege) is required a dcumented auditing prcess f cmpetency f OHCWs invlved in reprcessing and IPAC prcedures, including crrective measures if needed a regular schedule fr envirnmental cleaning f the reprcessing area that includes clearly defined respnsibilities managing hazardus waste (bihazardus, mercury, lead, sharps) 6

9 water and water use within the dental setting fr maintaining dental unit waterline quality during a Bil-Water Advisry (Safe Drinking Water Act, 2002, Ontari Regulatin 169/03 regulatry standards fr drinking water) suctin and suctin line maintenance prcedure fr immediate cntainment, cleaning and disinfectin f spills f bld and bdy fluids facilities maintenance (envirnmental cleaning, even if cntracted ut), such as a detailed schedule f cleaning f each area f the clinic sufficient equipment, supplies and technlgy fr all areas requiring envirnmental cleaning the maintenance f apprpriate service schedules and service recrds. 7

10 Occupatinal Health and Safety Requirements and Wrkplace Hazardus Infrmatin System (WHMIS) In Ontari, emplyers have the respnsibility t meet the requirements f the Occupatinal Health and Safety Act (OHSA) which includes the Ontari Regulatin 860: Wrkplace Hazardus Materials Infrmatin System (WHMIS). Emplyers and emplyees must cmply with prvincial legislatin and use any equipment, prtective devices r clthing required. Accrding t OHSA, it is a requirement that written plicies and prcedures are established t prtect health care wrkers in their wrkplace. The plicies and prcedures must include the fllwing: a specified health and safety representative r cmmittee t audit the health and safety prgram within the practice a written wrkplace vilence and harassment plicy a clear expectatin that OHCWs d nt cme t wrk when ill with symptms f infectin training fr all new emplyees, new equipment, and/r new jb prcedures wrkplace inspectins and hazard analysis investigatins f any accidents that may ccur in the wrkplace, including the management f needle stick injuries with specific pst-expsure prtcls knwing the immunizatin status f OHCWs is imprtant infrmatin fr the physician t have in the event f an injury the prhibitin f eating/drinking, strage f fd, smking, applicatin f csmetics and handling f cntact lenses in nn-designated areas a health and safety budget a frmal means f cmmunicatin t prmptly address the cncerns f wrkers material-handling practices and prcedures (see Wrkplace Hazardus Materials Infrmatin System) emergency prcedures, including medical emergencies first-aid and rescue prcedures fire preventin and emergency prcedures/evacuatin plan. 8

11 WHMIS is Canada s natinal cmmunicatin standard that deals with hazardus materials in the wrkplace. Accrding t WHMIS, any wrkplace that uses materials classified as cntrlled prducts is required t: use cautinary labelling n hazardus materials label must display the prduct identifier, safe handling precautins, and reference t the safety data sheets (SDS) maintain the mst current SDS fr all hazardus substances, which must be renewed every three years prvide wrker educatin prgrams n hw t use, handle, stre and dispse f hazardus material. A useful resurce, Wrkplace Hazardus Materials Infrmatin System (WHMIS): A Guide t the Legislatin is available at the Ontari Ministry f Labur website: 9

12 Human Rights The Ontari Human Rights Cde (the Cde) prvides fr equal rights and pprtunities, and freedm frm discriminatin. The Cde prhibits discriminatin based n any f the fllwing: Race Ancestry Place f rigin Clur Ethnic rigin Citizenship Creed Sex Sexual rientatin Gender identity Gender expressin Age Marital status Family status Disability The Cde recgnizes persns living with certain illnesses as disabled. As such, OHCWs must nt discriminate against such clients. This includes using additinal and/r unnecessary infectin cntrl practices r ther measures that are nt used fr ther clients. Mdificatins t rutine practices may be required based n the risks assciated with certain prcedures, prvided that they are used fr all clients underging the same prcedures. 10

13 Transmissin f Micrrganisms There are six elements in the chain f infectin. All six need t be present in rder fr infectin t spread. Absence f any ne f these elements will break the chain. Infectius Agent the pathgen that causes the disease (bacteria, fungi, parasites, viruses, prins) Reservir where the pathgen lives (peple, water, fd) Prtal f Exit the way the infectius agents leave the reservir (bld, secretins, excretins, skin) Mde f Transmissin the way the infectius agents are transferred (direct r indirect cntact, drplet, airbrne) Prtal f Entry the way the infectius agents enter the hst (mucus membrane, respiratry, skin, gastrintestinal tract) Susceptible Hst any persn at risk Infectius Agent Susceptible Hst Reservir CHAIN OF TRANSMISSION Prtal f Entry Prtal f Exit Mde f Transmissin It is critical that OHCWs understand the mdes f transmissin fr infectin t ccur in rder t prtect their clients, their clleagues and themselves. Visiting an ral health care setting presents the risk f expsure t pathgenic micrrganisms. 11

14 Understanding the mdes f transmissin is imprtant in the develpment f apprpriate IPAC principles. The three main mdes f transmissin f micrrganisms in an ral health care setting are: Direct transmissin (frm hands) Indirect transmissin (frm bject such as a dental scaler) Drplet transmissin (frm cughing r sneezing) 12

15 Oral Health Care Prvider and Client Safety Rutine Practices The Public Health Agency f Canada uses the term rutine practices t describe basic standards f infectin preventin and cntrl that are required fr safe client care. Rutine practices are based n the assumptin that all clients are ptentially infectius, even when symptms are nt clinically evident. The same safe standards f practice must rutinely apply t everyne when dealing with bld, bdy fluids and secretins (e.g. saliva), mucus membranes and nn-intact skin, in rder t break the chain f transmissin. There are five principles that are essential in rutine practices: 1. Risk assessment 2. Hand hygiene 3. Use f persnal prtective equipment 4. Envirnmental cntrls 5. Administrative cntrls Risk Assessment The first step fr an effective use f rutine practices is the perfrmance f an at pint risk assessment by the OHCW, relevant t the task at hand. A pint-f-care risk assessment is applied befre and at every interactin with the client, including: When bking and/r cnfirming f appintments (if apprpriate, e.g., same day r next day appintment). A gd pprtunity t screen clients in advance fr illness is when cnfirming dental hygiene appintments. Upn arrival in the receptin area. All clients must be prescreened fr any symptms f cmmunicable disease r acute respiratry infectins such as influenza, fever, cugh, vmiting, diarrhea, r cld and must be rescheduled in rder t prevent the spread f micrrganisms. An apprpriate sign t alert clients t reprt the abve symptms must be displayed prminently in the receptin area. In the dental hygiene peratry. OHCWs must screen the client t determine whether the client has a cmmunicable disease and t assess the risk f expsure t bld, bdy fluids, secretins, excretins and nn-intact skin and thus identify the strategies that will decrease expsure risk thrughut the dental hygiene appintment. Fr mre infrmatin n specific cnditins which may require rescheduling f clients, please refer t the CDHO Knwledge Netwrk 13

16 OHCWs shuld check regularly with their lcal Public Health Unit fr any diseases which may require pre-screening. Hand Hygiene The term hand hygiene encmpasses washing hands with sap and water r the use f alchlbased hand rubs (ABHR). Hand washing with sap and water is required t remve visible sil, and remve/kill transient micrrganisms frm the hands. ABHR is the preferred methd f hand hygiene if hands are nt visibly siled. A hand care prgram supprts hand hygiene and includes actins taken t maintain healthy hands and fingernails. Maintaining gd skin integrity is imprtant in a thrugh hand hygiene rutine as intact skin is the first line f defense t prtect ne s self frm infectin. Fr a quick reference please refer t the 4 Mments f Hand Hygiene by Public Health Ontari. Hand hygiene must be perfrmed: BEFORE: initial cntact with a client making cntact with items in client envirnment entry int the treatment rm, even if the client has nt been tuched putting n persnal prtective equipment eating r drinking. AFTER: care invlving cntact with bld, bdy fluids, and secretins f a client, even if glves are wrn remving persnal prtective equipment mving between extra ral and intra ral prcedures cntact with a client r items in their immediate surrundings hands are visibly siled persnal bdily functins. 14

17 Alchl-Based Hand Rub vs Sap and Water Alchl-based hand rub (ABHR): preferred use when hands are nt visibly siled must cntain 70% 90% alchl takes less time than hand washing mre effective than hand washing with sap and water when hands are nt visibly siled requires mechanical rubbing actin t kill transient bacteria Hand washing with sap and running water: preferred when hands are visibly siled because alchl is inhibited by rganic matter requires mechanical actin f washing, rinsing and drying, which remves mst transient bacteria lifts and washes away micrrganisms must nt include bar saps. less drying t hands than sap and water kills the intended micrrganisms. *** Best evidence suggests that antimicrbial sap is equivalent t ABHR in terms f micrrganism reductin but is harsher n the hands and mre time-cnsuming t use. Alchl-based hand rub and liquid sap must be dispensed in dispsable cntainers and must nt be tpped up. A gd hand hygiene rutine shuld include a misturizer that is cmpatible with glves and the prduct being used t clean yur hands. 15

18 Effective Hand Hygiene Techniques [Surce: Just Clean Yur Hands] 16

19 Barriers t Effective Hand Hygiene Cnsider the fllwing barriers when perfrming effective hand hygiene: Cnditin f the hands: the presence f dermatitis, cracks, cuts r abrasins can trap bacteria and cmprmise hand hygiene. Barrier creams are absrbed by the skin and may actually be harmful as they trap agents beneath them. Nails shuld be shrt enugh (i.e. nt mre than 2 mm beynd fingertip) t allw thrugh cleaning underneath and nt cause glve tears. Acrylic nails harbur mre micrrganisms and are mre difficult t clean than natural nails. Artificial nails and nail enhancements (i.e. Shellac) are als assciated with pr hand hygiene practices and result in mre tears t glves. Studies have shwn that chipped nail plish r nail plish wrn lnger than fur days can harbur micrrganisms that are nt remved by hand washing. Gel plish has been shwn t damage nails, resulting in nail weakness, brittleness and thinning, putting nails at increased risk fr breaking. Nail art (adding decrative paint effects t nails) has been shwn t be assciated with utbreaks f infectin. i Accessries such as rings and watches are highly discuraged as they have the ptential t harbur micrrganisms. If wrn, rings must be limited t a single smth band withut prjectins r munted stnes and watches shuld be cvered by a glve r sleeve. Lng sleeves r jewelry shuld nt interfere with, r becme wet when perfrming hand hygiene. If watches and ther wrist jewelry are present, remve r push up abve the wrist befre perfrming hand hygiene. ii Artificial nails and nail enhancements are nt t be wrn by thse having direct cntact with a client/patient. 17

20 Persnal Prtective Equipment (PPE) General Cnsideratins Persnal Prtective Equipment (PPE) is wrn t prtect the OHCW and clients frm expsure t ptentially infectius material. PPE serves as a barrier t prtect frm expsure t splashing, spraying r spatter f bld, saliva r ther bdy fluids, and frm intrducing micrrganisms int deeper tissues by traumatic injuries. The selectin f PPE must be based n a thrugh risk assessment and the ptential fr transmissin f infectius agents. PPE includes glves, gwns and/r lab cats and facial prtectin (i.e. prtective glasses, masks, face shields) as well as any techniques r equipment (e.g. high-vlume suctin) used t prtect against diseases spread by drplets, spatter and sprays. PPE nt nly prtects the OHCW but als prtects the clients against any crss-cntaminatin frm previus clients. PPE shuld be remved prir t leaving the peratry. Single-use barriers, such as glves and masks, must be discarded immediately after use. Prtective Cvering Whenever spatter r spray is anticipated during dental hygiene prcedures, the use f a water-resistant gwn is required. Clinical and labratry cats r jackets are nt a substitute fr gwns where a gwn is indicated. Regular clinical attire (e.g. unifrms, scrubs) is nt intended t functin as prtectin against a hazard where spatter r spray is anticipated. If clinical attire becmes inadvertently cntaminated it must be changed. Clinical attire must NOT be wrn utside f the ffice r wrn hme. A gwn must be wrn if it is anticipated that arms and/r clthing will be in cntact with bld, bdy fluids, secretins r excretins. Gwn must be remved and discarded immediately after use and prir t leaving treatment and/ r reprcessing rm. Single use nly Lng sleeved and cuffed Full frntal cverage frm neck t mid-thigh r belw. Ftwear wrn in the client treatment and reprcessing areas, needs t have enclsed tes and heels and be easily cleaned. Hair must be secured and wrn away frm the face r prperly cvered with hair r a beard cvering. If hair cverings are wrn, they must be changed at least daily r mre frequently if siled. Staff invlved in reprcessing must cnfine all hair including facial and bdy hair. Staff must never share PPE. 18

21 Cntaminated PPE must never cme in cntact with clean surfaces; fr example, a cntaminated gwn must be remved and discarded prir t remving sterilized items frm the sterilizer. Clients clthing shuld be prtected against spatter and debris with plastic-lined single-use bibs. Bib chains/hlders require cleaning and lw-level disinfectin between clients r may be purchased in a single-use frm. Masks Surgical masks that cver the nse and muth must be wrn during dental prcedures t prtect the respiratry mucsa frm cming in cntact with drplets and spatter. Masks als frm the basis f prtectin fr diseases spread by the drplet rute (e.g. influenza). Masks lse efficiency ver time and must be changed when they becme cntaminated (wet, visibly siled and/r accrding t manufacturer s directins) and between clients. Masks are: t be wrn by OHCWs when perfrming aseptic r invasive prcedures t be securely cvering the nse and muth and substantial enugh t prevent drplet penetratin t be put n immediately befre the prcedure fr which it is required t be remved and discarded immediately after the intended use nt t be re-used (must be changed after each client r mre frequently as needed) nt t be tuched while being wrn nt t be hung arund the neck r under chin nt t be flded r stred in a pcket. Prtective Eyewear Prtective eyewear fr the client and the OHCW shields the eyes frm spatter and debris that may be created by the use f certain instruments (e.g. handpieces, ultrasnic instruments, air/water syringe) as well as prtectin frm sharps r freign bjects. Prtective eyewear: must always be wrn thrughut the appintment t shield the eyes and the cnjunctival mucsa frm spatter and debris generated during dental prcedures shuld be cmfrtable, fit securely, and nt interfere with visin is t be put n immediately befre the prcedure fr which it is required 19

22 is t be remved immediately after the intended use re-usable prtective eyewear including lupes, must be cleaned and disinfected after use r accrding t manufacturer s instructins fr use (MIFU), between clients, and nce they becme visibly cntaminated. Prescriptin eyeglasses fr ral health care wrkers are nt cnsidered apprpriate eye prtectin as they d nt prvide prtectin against splashes arund the tp and sides f the glasses. Glves Glves are wrn t prtect the hands f the OHCW frm cntaminatin. The fllwing shuld be cnsidered when using glves as a PPE: selectin f glves shuld be apprpriate t the task d nt replace the need fr hand hygiene apprpriate hand hygiene prtcls must be fllwed befre dnning and after remving must be wrn when cntact with mucus membranes, nn-intact skin, r bdy fluids is anticipated must be put n immediately befre the activity fr which they are being used must be remved and discarded immediately after the activity fr which they were used must nt be wrn utside any rm r area where they are required fr persnal prtectin must nt be washed and reused as saps and alchls can cmprmise the surface f the glve, leading t micr-perfratins and lss f integrity must be changed between care fr each client r mre frequently as necessary if using ltin, check with the manufacturer s recmmendatins regarding the cmpatibility f ltins with glves; fr example, petrleum-based ltins may weaken the glve material resulting in increased permeability. 20

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25 Latex Allergy/Sensitivity Many cmmn dental prducts such as glves, rubber dams and prphylaxis cups may cntain latex and pse a severe risk fr clients with latex allergies/sensitivities. Cnsider the fllwing: As part f the medical histry-taking prcess, questins shuld be asked relating t pssible latex allergy/sensitivity. Treat in an envirnment where cntact with latex prteins, either directly r airbrne, is kept as lw as reasnably achievable. Remve all latex-cntaining materials r devices frm the peratry. Always check labels f dental prducts fr latex cntent. The use f latex glves is nt recmmended. Allergic reactins have been reprted with the use f latex glves, and cnsideratin must be given t this when purchasing glves. If the OHCW r the client has a latex allergy, latex-free glves must be used. Envirnmental Cntrls Handling f Sharps and Expsure Preventin Sharps are devices that are capable f causing a cut r puncture wund. Sharps shuld be kept ut f the reach f clients and safely cllected in a clearly labelled puncture-resistant cntainer at pint f use and/r must be transprted t the reprcessing area in a leak-prf cvered cntainer (i.e. plastic tray with a secured hard plastic cver) r cassette. Expsures t bld-brne pathgens can ccur via percutaneus injuries, nn-intact skin, r thrugh the eyes, muth and nse. Injury preventin strategies include: maintaining gd skin cnditin; intact skin is the first line f defense as a barrier t disease transmissin using cclusive dressings t prtect nn-intact skin; wrk duties may need t be adjusted t accmmdate any large skin lesins ensuring needles are capped prir t use and immediately recapped using a ne-handed scp methd r cmmercial recapping device remving dispsable sharps frm the tray and dispsing inside an apprpriate sharps cntainer immediately after use transprting sharps by using a puncture-resistant secured cntainer when dispsal at pint f use is nt pssible remving burs frm handpieces immediately after use wearing heavy-duty utility glves and apprpriate PPE when cleaning instruments. 23

26 In Ontari, all health care settings shall use safety-engineered needles, accrding t the Needle Safety Regulatin (O. Reg. 474/07). The regulatin is available at: Expsure Management Pathgens that are bld brne such as Hepatitis B (HBV), Hepatitis C (HCV), and Human Immundeficiency Virus (HIV) can be transmitted t OHCWs thrugh the expsure t bld, saliva and ther bdy fluids via a puncture/laceratin r by splashing nt nn-intact skin r mucsa f the eyes, nse r muth. An expsure management prtcl must be included in the IPAC manual and must include the fllwing: First aid prcedures fr the management f expsure t bld-brne pathgens Treatment by the apprpriate health care prfessinal (persnal physician r emergency department). This may include cunselling, pst-expsure screening, baseline and fllw-up serlgy and/r pst-expsure prphylaxis Dcumentatin f the incident Include the name and vaccinatin status f persns expsed Recrd the date and time f the incident and what the OHCW was ding, including the dental hygiene prcedure being perfrmed Identify what preventive measures were being implemented at the time f expsure (i.e. use f utility glves while handling sharp instruments) Dcument name (case number) and health status f surce persn if knwn, including any knwn bld-brne diseases (e.g. Hepatitis B, Hepatitis C r HIV indicated n their medical histry). All ral health care wrkers shuld be aware f the expsure management prtcl and shuld review it peridically. 24

27 Administrative Cntrls Educatin and Training OHCWs receive educatin in IPAC in their prfessinal prgrams. It is their respnsibility t ensure that current scientifically accepted infectin cntrl practices are in place and fllwed. In additin t their frmal training, OHCWs, including thse wh wn their wn clinic, need t ensure: frmal IPAC educatin and training apprpriate t their psitin and respnsibilities is prvided upn hire, at least annually, and whenever new equipment r prcesses are intrduced regular cntinuing educatin is required and shuld be supprted, as well as encuraged thse assigned t reprcess dental equipment/devices/instruments receive device-specific reprcessing instructins frm the manufacturer and seek clarificatin r educatin as required there are regular dcumented internal audits t assess the cmpetency f staff invlved in IPAC prcedures IPAC Manuals are reviewed by all staff members and updated at least annually. Immunizatin Immunizatins are an imprtant cmpnent t infectin preventin and cntrl. They minimize the OHCWs ptential risk fr cntracting an infectius disease frm a client and frm transferring an infectius disease t clients and ther staff. All OHCWs shuld be aware f their persnal immunizatin status and ensure their vaccines are up t date. It is highly recmmended that health care prfessinals be immunized against: Refer t the Canadian Immunizatin Guide fr a cmplete list f recmmended immunizatins fr health care wrkers. Hepatitis B (HBV) Measles Mumps Rubella Varicella Influenza Diphtheria Pertussis Tetanus Pli Illness and Wrk Restrictins Hand hygiene is the single mst imprtant measure in prtecting clients and clinicians frm the transmissin f micrrganisms. Hwever, even with the best f effrts, a clinician may fall victim t micrrganisms and becme ill. 25

28 When shuld an OHCW nt wrk n clients? If they have acute cnjunctivitis If they have severe respiratry illness with fever If they have influenza r a cmmn cld If they have acute viral gastrenteritis with vmiting and diarrhea If they have nn-intact skin lesins, they may need t adjust their wrk duties until any skin lesins have been reslved If an OHCW is immuncmprmised, they are at an increased risk f becming infected, therefre, when pssible, cnsideratins fr wrk duties and expsure risk shuld be taken int accunt. Additinal Precautins In sme cases, rutine practices may nt be sufficient fr clients wh are infected r clnized with certain micrrganisms. The term additinal precautins refers t measures that are taken in additin t rutine practices t break the chain f transmissin f such micrrganisms. This is especially relevant fr OHCWs treating clients in health care institutins, such as a lng-term care hme. Clients with weakened immune systems and chrnic illnesses are mre susceptible t methicillin-resistant Staphylcccus aureus (MRSA), vancmycin-resistant entercccus (VRE), r respiratry tract viruses like influenza. Clients wh may be suspected f having infectins transmitted by respiratry drplets must be rescheduled until the perid f cmmunicability is ver. In emergency situatins, persns wh are knwn r suspected f having infectins that can be transmitted by respiratry drplets shuld be ffered a mask and hand hygiene upn arrival, and ideally, shuld maintain a distance f tw metres frm thers in the ffice. The use f dental hygiene instruments such as ultrasnic scalers, handpieces, air plishers and the air/water syringes may create sprays, drplets r spatter. Every effrt shuld be made t reduce the spread by using a high-vlume suctin r a rubber dam. Using these items will als reduce the pssibility f yur client ingesting r inhaling cntaminated material and/r debris. Accrding t the Ministry f Health and Lng-Term Care dcument Occupatinal Health and Safety and Infectin Preventin and Cntrl in Health Care Settings, during a pandemic influenza warning, a N95 respiratr is required fr OHCWs. 26

29 Reprcessing In rder t prevent transmissin f micrrganisms, all reusable dental equipment and instruments being used n clients must be cleaned, disinfected and/r sterilized accrding t the current standards and guidelines frm the Prvincial Infectius Diseases Advisry Cmmittee (PIDAC), Canadian Standards Assciatin (CSA), and Public Health Agency f Canada (PHAC). General cnsideratins include: Manufacturers must supply infrmatin fr all dental equipment/instruments and decntaminatin equipment. Facilities must maintain manufacturers instructins in a frmat that allws fr easy access by staff carrying ut the reprcessing activities. Equipment that is used t clean, disinfect r sterilize must meet standards established by Health Canada and prvincial best practices. Designated staff assigned t reprcessing must be trained t a level required fr the vlume and cmplexity f the equipment t be reprcessed. There must be a written prtcl t deal with staff expsures that ccur during reprcessing (chemical expsures, heat expsure, and sharps expsure). 27

30 Classificatin f Client Care Equipment All dental equipment/instruments used in client care are categrized as critical, semi-critical, and nncritical. The classificatins f these equipment/instruments determine the minimal type f reprcessing required and the ptential risk f infectin assciated with their use. Categry Use Minimum level f reprcessing Examples Critical Enters sterile bdy site r vascular system Cleaned and sterilized Peridntal scalers, ultrasnic scaler tips and surgical instruments Semi-critical Cmes in cntact with mucus membranes r nn-intact skin Cleaned and sterilized If items are heat sensitive, then they need t be replaced by singleuse items Handpieces including mtrs and impressin trays Nncritical Cmes in cntact with nly intact skin and nt mucus membranes Clean and lw-level disinfectin Stethscpe, bld pressure cuff, shade guide, bib chain/hlder Newly purchased, nn-sterile critical and semi-critical dental/medical equipment/devices must be inspected and reprcessed prir t use, accrding t their intended use as per manufacturer's recmmendatins. Single-Use Items/Devices Single-use items are intended fr ne-time use nly and are t be discarded after each client. Single-use instruments/items include: such items as syringes, needles, prphylaxis cups and brushes, saliva ejectrs, glves, and bibs sme prphylaxis angles, high-vlume suctin tips and air/water syringe tips certain rthdntic brackets. 28

31 Single-use devices are usually nt heat-tlerant and cannt be reliably cleaned r disinfected. Therefre, they must be dispsed f apprpriately after use. Single-use items will be labelled with icns similar t the fllwing: Reprcessing Area The reprcessing area is where all instruments, devices and equipment are cleaned, disinfected, dried, packaged, sterilized and prepared fr reuse. The physical space used fr reprcessing instruments must have the fllwing: a clearly segregated area away frm direct client care and frm where clean, disinfected r sterile items are handled and/r stred a ne-way wrk flw frm dirty t clean t prevent crss-cntaminatin that include separate areas fr cleaning, rinsing/drying, packaging, and sterilizatin/cling a sink sufficient in size and depth fr cleaning client care equipment and instruments a dedicated handwashing sink r 70% 90% alchl-based hand sanitizers available fr use if a sink is nt available surfaces (walls, cabinets) capable f being cleaned and disinfected a sufficient cleanable, nn-prus cunter space t handle the vlume f wrk slip-prf flring that can withstand wet mpping the ability t cntrl the envirnment (e.g. temperature, ventilatin, humidity) readily available PPE (glves, gwns, mask, and/r eye prtectin) fr staff a plumbed r self-cntained eyewash statin within a 10-secnd walk (16 t 17 metres [55 feet]) f the reprcessing area that has a flushing capacity f minutes a puncture-resistant sharps cntainer. Any instruments r sharps that are transprted t the reprcessing area must be transprted in a leak-prf, puncture-resistant and sealed cntainer (e.g. plastic tray with hard plastic cver) r cassette. 29

32 Cleaning Reusable Dental Instruments/Devices Cleaning is the remval f grss debris, rganic and inrganic matter including bld and saliva. The fllwing criteria must be incrprated int cleaning rutines: Instruments must be pre-cleaned f grss debris immediately after use at chair side t ensure that rganic material will nt dry n them. If cleaning cannt be perfrmed immediately, instruments must be kept mist and placed in a puncture-resistant hlding cntainer and saked with a detergent r an enzymatic cleaner t prevent drying f rganic material. If an instrument is nt cleaned, remaining rganic and inrganic matter may prevent effective disinfectin and sterilizatin. All instruments and devices must be cleaned accrding t manufacturers directin. This may include disassembly f remvable parts and pening f hinges. Manual Cleaning Cleaning is achieved by manually scrubbing the instruments with a surfactant, detergent, r an enzymatic cleaner and must be dne while immersed in water t minimize splashing. The brush used fr scrubbing instruments must be inspected frequently and rinsed thrughut the day. All brushes must be dispsed r sterilized at the end f each day. Instruments must be rinsed after cleaning t remve any disinfectant, r surfactant residue. Instruments must be dried with a lint-free clth r designated autmatic dryer. Instruments must be visually inspected t ensure all rganic and inrganic materials have been remved and integrity f the instruments has nt been altered. T prevent injury when handling cntaminated and sharp instruments, the fllwing precautins shuld be taken: Using puncture-resistant utility glves Nt reaching int trays r cntainers that are hlding sharp instruments that cannt be seen (fr example, sap-filled sinks) Using a lng-handled brush if manually scrubbing instruments Wearing a mask, prtective-eyewear, and gwn t prtect frm sprays, splashes and spatter. 30

33 Ultrasnic Cleaner Equipment must be tested fr efficacy at least weekly and preventive maintenance shuld be perfrmed accrding t the MIFUs. Basket must nt be verladed and lid must remain n especially when in use. Instruments must be rinsed after cleaning t remve any disinfectant, r surfactant residue. Instruments must be dried with a lint-free clth r designated autmatic dryer. Instruments must be visually inspected t ensure all rganic and inrganic materials have been remved and integrity f the instrument has nt been altered. Detergent r enzymatic cleaning slutins must be discarded at the end f each day, r mre frequently, if they becme siled r cludy and as per the MIFU. A lg f all testing and maintenance prcedures must be maintained. Washer-Disinfectrs Washer-disinfectrs are cmputer-cntrlled units used fr cleaning, disinfecting, and drying slid and hllw surgical and dental equipment. Manufacturer s instructins must be fllwed fr the peratin, maintenance and testing f the washer-disinfectr t ensure that it wrks prperly. The cleaning and disinfecting prcess must be mnitred regularly accrding t the manufacturer s instructins and fully dcumented. Instruments must nt be stacked r verladed in the washer-disinfectrs and devices must be disassembled if required. Instruments must be dried with a lint-free clth if required. Instruments must be visually inspected t ensure all rganic and inrganic materials have been remved and integrity f the instrument has nt been altered. Disinfectin Lw t Intermediate Level Apprpriate Persnal Prtective Equipment (PPE) shuld be wrn during disinfectin. An apprpriate disinfectant must be selected that: has a Drug Identificatin Number (DIN) frm Health Canada has efficacy fr the intended use is cmpatible with the material t be disinfected (as per MIFUs) is safe fr use, with minimal txic and irritating effects t/fr staff. 31

34 Manufacturer s recmmendatins regarding the stability and integrity f material when selecting prducts fr disinfectin must be fllwed (e.g. amunt, dilutin, cntact time, safe use and dispsal). High Level (Cld Sak) The use f high-level disinfectant (HLD) is highly discuraged because f its txic vapurs, special ventilatin requirements, and its inability t destry sme micrrganisms. Preparing and Packaging f Reusable Dental Instruments/Devices All cleaned instruments must be prepared and packaged in a manner that will maintain sterility until use. Preparing and packaging must include the fllwing: Instruments requiring sterilizatin must be packed and/r wrapped accrding t MIFUs. Instruments must be prepared fr packaging in a manner that will allw adequate air flw and steam penetratin (e.g. avid ver filling packages). Hinged instruments must be packaged and prcessed pen and unlcked. Disassembled instruments/devices must remain disassembled until use. Suitable packaging materials culd include peel puches f plastic/paper, and wven r nnwven sterilizatin wrap that is cmpatible with the sterilizatin prcess being used. Each package must be labelled befre sterilizatin with: Date prcessed Sterilizer used Cycle r lad number Initials f the OHCW wh packaged the instruments. Labels must be placed n the transparent side f a plastic/paper puch r directly n the clsure tape f wrapped packages, taking care nt t blck the breathable area f the package. Permanent sft-tipped markers that have been validated fr the sterilizer shuld be used ensuring they d nt puncture r damage the packaging. The inside cntents f the package need t be labelled if instruments are nt visible (e.g. in a wrapped cassette). All packages must include bth external and internal chemical indicatrs. 32

35 Please see Mnitring Determining the Effectiveness f the Steam Sterilizatin Prcess sectin fr requirements fr physical, chemical and bilgical indicatrs n page 36. If quarantine pending BI results is nt pssible, evaluatin f a Type 5 r 6 chemical indicatr and the specific cycle physical parameters may be used t justify the release f rutine lads. There are cntingency plans (i.e. recall plicy and prcedure) in the event f reprcessing failures. 33

36 Sterilizatin f Reusable Dental Instruments/Devices Sterilizatin is the killing f disease-prducing micrrganisms, including spres. All critical and semicritical instruments/devices must be sterilized befre use n clients. When sterilizing, ensure that: written plicies and prcedures are in place fr the sterilizatin f instruments fllwing the MIFUs the MIFUs fr the installatin, peratin, cleaning and preventive maintenance f the sterilizing equipment are fllwed staff invlved are trained t perate sterilizers, including nging audits and dcumentatin f training all sterilizers are tested fr perfrmance using physical, chemical and bilgical mnitrs and indicatrs lading f packaged items int the sterilizer must fllw bth the MIFUs f the sterilizer and the individual instruments/items being sterilized temperature at which items are sterilized must fllw bth the MIFUs f the sterilizer and the individual instruments/items being sterilized all sterilized instruments/items must be fully dried in the sterilizer chambers prir t unlading when unlading items frm the sterilizer, heat-resistant mitts must be used and laundered at least weekly a recrd is kept f all maintenance and repairs perfrmed n all equipment used t sterilize instruments a lg is kept f all prcedures and results used t cnfirm prper functining f all sterilizers (physical, chemical and bilgical indicatrs). Steam Sterilizatin The mst cmmn methd f sterilizatin in a dental hygiene setting is thrugh the use f dynamic air remval sterilizers. Pre-vacuum table-tp sterilizers are recmmended, hwever, steam flush pressurepulse sterilizers are als acceptable fr clinical ffice settings. All sterilizatin equipment used must have a Health Canada medical device licence. The cycles available n the sterilizer must be cmpatible with the cycles required t sterilize yur instruments as per the MIFUs. 34

37 Unacceptable Methds f Sterilizatin The fllwing methds are NOT acceptable methds f sterilizatin. Dishwasher (including thse with sanitizing cycles) Biling Ultravilet irradiatin Glass bead sterilizers Chemiclave sterilizers Micrwave vens Flash Sterilizatin Flash sterilizatin, als knwn as immediate-use steam sterilizatin (IUSS), is a mdificatin f cnventinal steam sterilizatin in which an unwrapped item is placed in an pen tray r is placed in a specially designed, cvered, rigid cntainer t allw fr rapid penetratin f steam. Flash sterilizatin shuld nly be used in urgent emergency situatins where the instrument will be used immediately and n ther ptins are available. Client scheduling and/r lack f instruments d nt qualify as reasns t use flash sterilizatin. The fllwing must be cnsidered regarding the use f flash sterilizatin: A lg is kept f all particulars when this methd is used (i.e. client name, prcedure and instrument used). Instruments must be clean and dry prir t sterilizatin. Every cycle must be mnitred using the apprpriate indicatrs. Care is taken t prevent cntaminatin f instruments prir t use. A lg must be kept f immediate-use steam sterilizatin including cntents f the lad and cnfirming all physical parameters were met. Equipment/devices sterilized in this manner must be nted in the patient s chart alng with the ratinale. 35

38 Mnitring Determining the Effectiveness f the Steam Sterilizatin Prcess Mnitring f the sterilizer must be dne rutinely and invlves the evaluatin f physical, chemical and bilgical parameters. Physical Physical indicatrs are the gauges r displays n the sterilizer fr cycle time, temperature and pressure. Newer sterilizers have the capability t print results and/r recrd digitally. Physical indicatrs must be checked and recrded fr each lad. Readings that indicate the required time, temperature and pressure have been reached d nt ensure sterilizatin was successful and fr this reasn chemical and bilgical testing must als be used. Hwever, unacceptable readings must be investigated. Chemical Chemical indicatrs (CI) (internal and external) use sensitive chemicals t access physical cnditins such as time, temperature and presence f steam. Chemical indicatrs must be used n the inside and utside f each package t shw that it has undergne a sterilizatin cycle. The clur change alne is nt enugh t prve that sterilizatin has been achieved. External indicatrs are intended t indicate that the unit has been directly expsed t steam fr a minimum amunt f time and is used t distinguish between a prcessed and unprcessed package. Each package must have an externally visible Type 1 indicatr. Internal indicatrs are intended t respnd t ne r mre chemical r physical change. An internal CI must be placed in each package that is underging sterilizatin in the area least accessible t steam penetratin. At minimum an internal Type 4 indicatr must be used in each package. Classes f Chemical Indicatrs Type Descriptin Cmmn Uses Type 1: Prcess Indicatrs Type 2: Specific Test Indicatr Used t differentiate prcessed frm nn-prcessed items Indicatr is used in specific tests r prcedures t evaluate sterilizer perfrmance Its purpse is t evaluate prper air remval frm the sterilizer Respnds t ne r mre critical prcess variables Usually applied t the utside f packages E.g. Peel back puches usually have a chemical indicatr manufactured n the paper side f the package and chemical indicatr tape is als available T be used with dynamic air remval (prevacuum) sterilizer and must be perfrmed each day the sterilizer is used E.g. Bwie-Dick Test 36

39 Type 3: Single Variable Indicatr Type 4: Multi-Variable Indicatr Type 5: Integrating Indicatr Type 6: Emulating Indicatr Reacts t a single critical prcess variable (i.e. temperature r time) Indicatr reacts t tw r mre critical variable in the sterilizatin cycle The manufacturer specifies the cnditins under which the parameters are met Respnds t all critical variables in the sterilizatin prcess (i.e. time, temperature, presence f steam) Indicatr reacts t all critical variables (time, temperature and presence f steam) fr a specified sterilizatin cycle (i.e. 10 min, 18 min, 40 min) Expsure cntrl mnitring in a specific lcatin Rarely used in dental settings May be used fr prcess cntrl E.g. Indicatr strips are manufactured inside n the paper side f the peel back puches Used as an internal CI prcess cntrl Respnds t all critical variables in the same way that a BI respnds May be used as an additinal mnitring tl t release lads that d nt cntain implants E.g. Indicatr strips Used as an internal CI prcess cntrl A different Type 6 emulating indicatr is required fr each sterilizatin cycle time and temperature used May be used as an additinal mnitring tl t release lads that d nt cntain implants Ontari Agency fr Health Prtectin and Prmtin (Public Health Ontari). Prvincial Infectius Diseases Advisry Cmmittee. Best practices fr cleaning, disinfectin and sterilizatin f medical equipment/devices. 3 rd ed. Trnt, ON: Queen s Printer fr Ontari; May Bilgical Bilgical indicatrs (BI), als knwn as spre tests, use viable micrrganisms (e.g. spre-laden strips r vials) t test sterilizer efficacy. Spre tests are the mst accepted means fr mnitring sterilizatin because spres are the mst difficult micrrganisms t kill. When chsing a BI spre test, the micrrganism used t test must be cmpatible with the sterilizatin prcess being used. Fr example, Gebacillus stearthermphilus is the best micrrganism t use t test efficacy f steam sterilizatin. A passed BI indicates that live spres have been killed, and therefre, indicates that all ther micrrganisms have als been killed. BI testing must be dne each day a sterilizer is used and with each type f cycle. Best practice is nt t release items f the prcessed lad until the results f the BI test are available. Prcess Challenge Devices (PCD) A prcess challenge device is a test device intended t prvide a challenge t the sterilizatin prcess that is equal t r greater than the challenge psed by the mst difficult item rutinely prcessed. (1, 2) A PCD is used t cnfirm that a sterilizer has effectively sterilized ALL items prcessed in that cycle. One example f a PCD is a set f instruments with a BI spre test and a Type 5 indicatr strip inserted inside the package. This package is then placed in a rutine lad with ther instrument puches r wrapped cassette t challenge and test the sterilizatin prcess. If these tw tests shw that all spres have been killed in the BI test, all critical variables have met r exceeded the perfrmance 37

40 requirements accrding t the Type 5 indicatr results, and that all physical parameters (time, temperature and pressure) have been verified, yu can be cnfident that the sterilizatin prcess has been effective and that the sterilizer is wrking prperly. It is imprtant t nte that a PCD must nly be used fr the sterilizer type and sterilizatin cycle fr which it is intended (2). The three types f PCDs mst cmmnly encuntered in a dental hygiene practice are: 1. Air remval/bwie-dick PCD test pack 2. A bilgical indicatr PCD test pack 3. A chemical indicatr PCD test pack Air Remval/Bwie-Dick PCD Test Pack If using pre-vacuum sterilizer, a Bwie-Dick PCD test pack (Type 2 CI) must be perfrmed in an empty sterilizer at the beginning f each day it is used. The MIFUs f bth the sterilizer and PCD will indicate where the test pack shuld be placed in the sterilizer. It is critical t cnfirm the type f sterilizer being used as this test is nly required fr pre-vacuum sterilizers. An air remval/bwie-dick PCD test pack can be purchased cmmercially and is used t assess if air has been prperly evacuated and whether any air leaks are present. Once the cycle cntaining the test pack has passed, recrd the results and dispse f the test pack. Fr all sterilizers, fllw the manufacturer s instructins fr relevant sterilizatin mnitring tests. Bilgical Indicatr PCD Test Pack A BI PCD test pack is used fr daily mnitring f sterilizers and is placed in the chamber with a full lad f items t be sterilized. This must be cmpleted nce a day at the same time fr each type f cycle (i.e. wrapped, plastics, handpieces, etc.) A BI PCD test pack can be either prepared cmmercially r in ffice. T prepare yur wn, cnsider all packages rutinely sterilized and chse the ne that is mst challenging t sterilize. Fr example this culd be cnsidered a package that has the mst instruments. The package must be assembled as indicated by the MIFU, with a BI spre test and a Type 5 CI strip added in the area f the package where steam wuld have mst difficulty penetrating. The package must be sealed and labelled PCD. A BI PCD test pack must be placed in the area f the lad that will be clest during the cycle. T determine the clest areas, the MIFUs must be fllwed. Upn cycle cmpletin, the BI is t be remved frm the PCD test pack, prepared and incubated fr the recmmended time as indicated by the MIFU. A cntrl BI, frm the same lt as the test indicatr nt prcessed thrugh the sterilizer, must be prepared and incubated with the test BI; effective sterilizatin is indicated when the cntrl BI yields psitive results fr bacterial grwth while the sterilized BI yields negative results. 38

41 The Type 5 CI must als be checked. If the results indicate a pass and all physical parameters have been met (time, temperature, pressure), the instruments may be released fr use. Once the PCD test pack has been pened, it is n lnger sterile, and therefre, all items within the PCD test pack must be repackaged with new indicatrs and re-sterilized. Althugh instruments can be released based n the results f the chemical indicatr (Type 5), best practice is t quarantine the lad until results f the BI are available. A lg must be kept dcumenting the date and time f sterilizatin, sterilizer number, sterilizer cycle, and lcatin f the PCD within the cycle. Once the results are available and dcumented, the BI may be dispsed f accrding t the MIFU. The results f all sterilizatin mnitring tests must be recrded and retained fr 10 years as per the CDHO Recrds Regulatin. Bilgical Indicatr PCD Failure In the event a BI PCD yields psitive results fr bacterial grwth (a failed test), the OHCW shuld fllw the steps belw t ensure the client s safety: 1. Infrm the supervisr/wner f the practice. The supervisr/wner will want t knw the time and date f failure, sterilizer and lad/ cycle number in questin, CI results, results f physical mnitring, BI results, and any ther infrmatin that may be useful in determining the prblem. 2. Investigate the prblem. Review cycle parameters (physical and CI) since the last negative BI (successful test) result Discuss the pssibility f errrs such as verlading, failing t prvide acceptable package separatin, and using incrrect and/r excessive packaging material with all equipment peratrs. 3. Temprarily take sterilizer ut f service and quarantine all instruments back t previus negative BI (successful test). 4. Retest the sterilizer with a secnd BI PCD test. While waiting fr the test results, the sterilizer shuld remain ut f service. 5. If the repeat BI PCD test is negative fr grwth (successful test) and chemical and physical indicatrs demnstrate adequate prcessing, the sterilizer may be put back int service. All items frm the failed lad must be resterilized. 6. If the repeat BI PCD test is psitive fr grwth (failed test) and all sterilizatin prcedures have been perfrmed accurately, the sterilizer must remain ut f service and be inspected and repaired. Prir t returning the sterilizer t service, it must be qualified with three BI PCD tests in three cnsecutive empty chamber cycles. All three tests must yield negative results. Initiate recall prtcl, which means all items frm suspect lads dating back t the last negative BI must be recalled, t the extent pssible, and reprcessed. 39

42 7. Fllw the recall prtcl fr client ntificatin as per plicy, including cnsulting with yur lcal public health unit fr risk assessment and t determine if client ntificatin is necessary. 8. Keep a recall lg f all maintenance assciated with a psitive BI PCD test. Chemical Indicatr PCD Test Pack A CI PCD test pack measures tw r mre variables fr the area in the sterilizer in which it is placed. If the sterilizer has a printer/usb, and instruments are nt quarantined, a CI PCD test pack cntaining a Type 5 CI must be placed in every subsequent lad after the BI PCD test pack lad. The remainder f the packages in the lad need t have a Type 1 CI n the utside and a Type 4 CI n the inside. If the sterilizer des nt have a printer/usb, plan t replace it with ne that des. In the meantime, all the physical parameters (time, temperature, pressure) need t be evaluated and dcumented manually, and a Type 5 CI must be used in every package. The easiest way t assemble a chemical indicatr test pack in ffice is t chse the instrument pack that is mst challenging t sterilize (i.e. the package with the mst instruments) and insert a CI strip (Type 5) in the area f the package where steam wuld have the mst difficulty penetrating. The package shuld be sealed and labelled as a PCD. The CI PCD test pack shuld be placed in the area f the lad that will be clest during the cycle. T determine the clest areas, the MIFUs must be fllwed. Once the lad cntaining a CI PCD test pack has been sterilized, the Type 5 CI within the PCD shuld be evaluated fr a successful pass and all physical parameters shuld have been met (time, temperature, pressure). Once cnfirmed, the instruments may be released fr use. As sn as the CI PCD test pack has been pened, it is n lnger sterile and therefre all items within the CI PCD test pack must be repackaged with new indicatrs and re-sterilized. If Instruments are quarantined and the sterilizer has a recrding device (i.e. USB/printer), every package must have an external Type 1 CI and an internal Type 4 CI. CI, CI PCD and/r Physical Parameters Failures 1. Infrm the supervisr/wner f the practice. The supervisr/wner will want t knw the time and date f failure, sterilizer and lad/ cycle number in questin, CI results, results f physical mnitring, BI results if available and any ther infrmatin that may be useful in determining the prblem. 2. The sterilizer shuld be temprarily taken ut f service. 3. The cause f the failure shuld be investigated. 4. If the failure is cnfined t ne lad and can be immediately crrected, simply crrect the prblem and reprcess the lad. 40

43 If a failed CI is fund in ne package, the cntents f the package must be reprcessed befre use. If a failed CI is fund in multiple packages, r if any physical parameters are nt met, the entire lad must be reprcessed. 5. If the failure cannt be immediately crrected, recall and reprcess all items back t the last successful lad (bth CI and physical parameters met). 6. If a majr repair is dne, requalify the sterilizer (see sectin belw fr qualifying and requalifying sterilizers). 7. Keep a lg f all maintenance assciated with any failed tests. D nt use any reprcessed instrument if there are any dubts abut the sterility f instruments. 41

44 42

45 Lgging the Sterilizatin Prcess A lg bk must be maintained fr each lad sterilized. This is a key cmpnent f the recall prtcl as it allws fr identificatin f clients wh may have been expsed t nn-sterile instruments r equipment. The lg bk needs t include: 1. Date 2. Lad number 3. Time cycle started 4. Cycle parameters (ttal time f cycle, pressure and temperature reached) 5. Lad cntents 6. Internal and external chemical indicatr results (pass r fail) 7. Bilgical and chemical indicatr results via BI and CI PCDs (pass r fail) Dcumenting a Recall Incident A recall lg must be kept f all failed tests utlining the prcedures fr the recall f imprperly reprcessed items. The fllwing shuld be included: 1. Circumstances (i.e. failed tests) that prmpted a recall rder 2. A list f medical devices, sterilizers, lads included in the recall 3. A list f supervisrs, wners r public health units that were ntified f the recall 4. A list f items that were rdered fr recall but nt cllected (i.e. thse that were already used n clients) 5. The crrective actins taken t reslve the issue and prcedures implemented t prevent re-ccurrence 6. The client ntificatin prcedures Qualifying and Requalifying Yur Sterilizer Sterilizers must be rigrusly qualified n installatin and requalified fllwing disruptins t their nrmal activity. They must be installed accrding t the manufacturer s instructins by a qualified technician and must pass three cnsecutive cycles with the apprpriate Bwie-Dick (if required), and three BI PCDs placed in three additinal empty lads. Finally, the sterilizer must be qualified with at least ne full BI PCD test lad, befre the sterilizer can be put int rutine service. A sterilizer must nt be apprved fr use if any indicatr(s) yield a failed test n any f the tests cnducted fr the purpses f qualifying r requalifying the sterilizer. 43

46 Sterilizers must be mnitred with a test lad and be fully requalified annually and under the fllwing circumstances: 1. The purchase and installatin f a new sterilizer r laner sterilizer 2. After cnstructin r ther envirnmental changes in the area 3. The relcatin f a sterilizer 4. After the sterilizer is repaired r mdified 5. After unexplained sterility failure. Strage f Reprcessed Dental Instruments / Single-Use Devices All items must be carefully handled and stred t avid cntaminatin thrugh small, ften undetected hles: in a clean, dry, misture- and dust-free area (e.g. clsed shelves r cntainers) away frm high areas f traffic nt under sinks as this may cause cntaminatin. If the integrity f the package has been maintained during strage, the sterilized items remain sterile. A plastic jacket may greatly extend the shelf life f the package and shuld be used n muslin- r crepewrapped packs. The expiry dates that sme manufacturers put n their packaging prducts must als be fllwed. Prir t use, sterile packages/bags must be checked t ensure that the sterility has nt been cmprmised by: visually inspecting fr disclratin, dampness, dust, sil, and tears validating CI results checking fr defects in the instruments. It is a standard f practice fr dental hygienists t ensure that current scientifically accepted IPAC guidelines are in place and fllwed. Other team members may be invlved in the reprcessing, but ultimately, the dental hygienist as the end user is respnsible fr verifying whether the equipment used n his/her client is sterilized and treatment is prvided In a clean and safe envirnment. 44

47 Envirnmental Cleaning Dental hygiene services shuld nly be prvided in envirnments that are able t supprt safe, quality care. When evaluating the envirnment, OHCWs shuld cnsider ways in which t minimize the transfer f micrrganisms frm siled hands, siled instruments r siled envirnmental surfaces. When chsing finishes and furnishings fr the clinical practice setting, seamless, nn-prus and easy t clean items shuld be cnsidered. There are tw categries f envirnmental cleaning fr clinical ffice settings: Public cntact surfaces (lw-tuch surfaces) Clinical cntact surfaces (high-tuch surfaces) Public Cntact Surfaces Generally, there is minimal risk f micrrganism transmissin in these areas as they typically d nt cme int cntact with bld and saliva. Sme examples f public cntact surfaces include the receptin area (e.g. chairs, tys, cuntertps, etc.), cnsultatin rms and business ffice. T minimize the risk t clients and staff, any siled clthing (lab cats/gwns wrn during treatment) and PPE must be remved after leaving treatment rms and befre entering public spaces. These areas shuld be cleaned daily, r mre frequently, if siled. Flrs shuld be HEPA-filter vacuumed and/r wet mpped daily. Mp heads and buckets must be cleaned thrughly between uses and allwed t dry cmpletely. Mps used in clinical cntact areas shuld nt be used in public cntact areas. Carpeted areas and uphlstered furnishings are discuraged, hwever, if used, must be cleaned n a regular schedule. In the event public cntact surfaces becme siled with bld r bdy fluids (i.e. a client vmits in the receptin area), using apprpriate PPE, the surfaces must be cleaned first, and then disinfected fr the apprpriate cntact time accrding t the prduct s MIFUs. Clinical Cntact Surfaces Carpeted areas, uphlstered and wd furnishings are nt acceptable in treatment rms r instrument reprcessing areas as they are difficult t clean and disinfect. Clinical cntact surfaces are very likely t be cntaminated with bld and bdy fluids thrugh direct spray, spatter, cntaminated instruments, r frm the clinician s glved hands. 45

48 High-cntact surfaces include: Dental chair/switches Overhead light handle and switches Chairside cmputer keybards, mnitrs and muse Radigraphy equipment Intraral cameras Drawer and dr handles Sink and faucet handles Cuntertps Telephnes (if in peratry) and pens Clinical cntact surfaces include thse high-tuch surfaces that are in the immediate area f client treatment and must be cleaned f grss debris and then disinfected with a lw-level disinfectant between every client and at the end f each wrk day. Treatment areas must be free f clutter and unnecessary supplies and equipment n cunter tps in rder t minimize cntaminatin with spatter, drplets r sprays and facilitate effective disinfectin. Apprpriate PPE must be wrn while disinfecting surfaces t prevent ccupatinal expsure t infectius micrrganisms and chemicals. Barriers Barriers shuld be used n high-tuch surfaces that are difficult t clean and disinfect. Suitable barriers shuld be misture-prf such as plastic bags r plastic sheets. Cnsideratin shuld be given t using barriers n: expsure buttn n radigraphy equipment switches f lw- and high-vlume suctins buttns f air/water syringe cmputer keybards, muse and mnitr screen headrest verhead light handle and switches radigraphy equipment and digital sensrs intraral cameras Barriers must be changed between clients using apprpriate PPE. Areas cvered by barriers shuld be disinfected and allwed t dry cmpletely prir t placing a new barrier as these areas may becme cntaminated during treatment. Any surfaces that cme int cntact with bld and saliva must be readily cleaned first, and then disinfected. 46

49 Waste Management Waste must be separated int bimedical waste (hazardus waste) and general ffice waste then dispsed f in an apprpriate manner t prevent the transmissin f pssible infectins frm cntaminated waste. Bimedical Waste Bimedical waste requires special strage, handling and dispsal accrding t Ontari prvincial and municipal regulatins. Bimedical waste must be: stred in clur-cded cntainers that are marked with the universal bihazard symbl released t an apprved bimedical waste carrier fr dispsal. Bld-saked materials (release liquid r semi-liquid bld if cmpressed) Bld-saked materials must be placed in a YELLOW liner bag labelled with the universal bihazard symbl. If bld-saked materials are t remain n site fr mre than fur days, they must be stred in a refrigerated strage area marked Bimedical Waste Strage Area displaying the universal bihazard symbl. Bld-saked materials must be released t an apprved bimedical waste carrier fr dispsal If gauze, cttn rlls, and examinatin glves d nt release liquid r semi-liquid when cmpressed, they are cnsidered general ffice waste. Fr mre infrmatin refer t Best Management Practices fr Dispsal f Bimedical/ Pathlgical Waste in Ontari Sharps (needles, syringes with needles, scalpel blades, clinical glass, scalers and cavitrn tips, etching tips, etc.) Sharps must be dispsed f in a YELLOW puncture-resistant, leak-prf cntainer specifically designed fr their management and labelled with the universal bihazard symbl Cntainers must nt be filled beynd their designated capacity Must nly be released t an apprved bimedical waste carrier fr dispsal. 47