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Dr. Abdelmonem Altarhony Infection control measures II Objectives At the end of the course, the students should have an understanding of: • Administrative controls • Engineering controls Infection Control Program Infection Control Program is designed to: Minimize the risk of infections to patients and staff. Limit unprotected exposure. Provide training. Meet government and Joint Commission regulations and standards. The Program includes: Identification of Infection Risks Infection Prevention Intervention Infection Control Intervention Infection Surveillance and Reporting Patients Staff Exposure Control Plan & Check lists • The Organizational Exposure Control Plan lays down procedures, practices, vaccination requirements, and a appropriate Reporting for incidents of exposure in a health environment. • The plan specifies the agents and procedures to be used for disinfection and sterilization, and where each is to be applied. • Guidelines and materials arranged in tabular form are easy to follow, and provide an overview. Checklists for individual areas, e.g. for equipment and room disinfection, assist the personnel responsible for each procedure. The hygiene measures should also include guidelines for regulating patient appointments: treatment of infectious patients should be scheduled at the end of the day. An effective Infection Control Program is based on a hierarchy of infection control measures. These include: • Administrative controls • Engineering controls • Work place controls Administrative controls include: 1. Developing and implementing effective policies and procedures to en ensure the rapid identification, isolation, evaluation, and treatment of persons with signs and symptoms of infective disease, 2. Educating healthcare workers about infectious diseases and teaching clients good infection control practices, e.g. using a tissue when coughing, washing hands… 3. Maintaining an effective employee screening program, which includes respiratory protection and education relevant to infectious diseases control. Personnel Health Elements of an Infection Control Program • • • • Education and training Immunizations Exposure prevention and postexposure management Medical condition management and work-related illnesses and restrictions • Health record maintenance Infection Control Training • New employees must demonstrate proficiency in Infection Control and Prevention before having contact with patients or handling equipment. • Education of health care providers, clients and families/visitors/caregivers. • Annual, documented training and competence testing as required by OSHA (Occupational Safety and Health Administration) and other agencies on the following Infection Control topics: – Infectious Disease: Prevention and Control – Bloodborne Pathogen and Bio-Hazardous Waste – Tuberculosis; Symptoms and Precautions Infection Monitoring • Any infectious condition shall be noted to alert staff. • Delivery and cleaning staff should use standard precautions and follow the infectious plan procedures when servicing patients identified with an infectious condition Infection Monitoring Staff should receive education on when to stay home from work in a health care setting. This includes: 1. Febrile respiratory illness 2. Dermatitis on their hands (consult your physician about your risk) 3. Cold sores or shingles that can’t be covered 4. The initial days of a respiratory illness 5. Diarrhea 6. Eye infections until treated Most employers of health care providers will have policies in this regard. Infection Reporting • The Operations Manager is to be notified immediately whenever an actual or suspected infectious condition exist. • Any incident involving the patient and/or staff member contracting an infectious condition traceable to the other shall be reported immediately. – To the Operations Manager – Accident/Incident Report Form Follow-up for punctures or mucous membrane exposures to bloodborne pathogens Ensure you know the procedure at your facility • First Aid: Rinse, wash and clean involved area after exposure • Recognize importance of medical follow-up (use of Post-Exposure Prophylaxis within one to two hours can reduce HIV transmission by 90%) • Medical follow-up at appropriate agency to be assessed for bloodborne pathogens: Hepatitis B, Hepatitis C and HIV • Proper follow-up includes; • Significance of exposure Risk factors Prophylactic medication if indicated Education and counselling for informed consent and testing if required Precautions necessary If testing is required – serial testing should be conducted at time of exposure, then at three and six months. Occupational Injuries Sharps injury/contamination incident includes: 1. Inoculation of blood by a needle or other ‘sharp’ instroments. 2. Contamination of broken skin with blood 3. Blood splashes to mucous membrane e.g. eyes or mouth 4. Swallowing a person’s blood e.g. after mouth-to- mouth resuscitation 5. Contamination where clothes have been soaked by blood 6. Bites. Factors Influencing Occupational Risk of Bloodborne Virus Infection 1. Frequency of infection among patients 2. Risk of transmission after a blood exposure (i.e., type of virus) 3. Type and frequency of blood contact Characteristics of Percutaneous Injuries Among DHCP • • • • • Reported frequency among general dentists has declined Caused by burs, syringe needles, other sharps Occur outside the patient’s mouth Involve small amounts of blood Among oral surgeons, occur more frequently during fracture reductions and procedures involving wire Transmission of HVB AND HIV from Infected Dentists to Patients • Prevalence of HCV infection among dentists similar to that of general population (1%-2%) • No reports of HCV transmission from infected DHCP to patients or from patient to patient • Risk of HCV transmission appears very low • Only one documented case of HIV transmission from an infected dentist to patients • No transmissions documented in the investigation of 63 HIV-infected HCP (including 33 dentists or dental students) Flu Standard Precautions • Avoid close contact • Stay at home or take respiratory precautions when you have the flu (wear a mask) • Cover your mouth and nose when you cough or sneeze • Keep your hands clean and avoid touching your eyes, nose or mouth • Healthcare workers must: be medically assessed by their doctor if they have a persistent cough and practice respiratory hygiene/ cough etiquette Recommended vaccination for Health Care workers Recommended for the dentist, dental student, and auxiliary. • (No vaccine against hepatitis C is available.) • Annual influenza immunization • Measles, Mumps and Rubella (MMR) – two doses • Tetanus Diphtheria and Polio (TDP) • Hepatitis B (full series with follow up blood work to determine conversion) • For susceptible health care providers, varicella vaccine is recommended • Tuberculosis B. Engineering controls • Engineering controls are built into the design (Rx room, private bathrooms, private rooms, HVAC (Heating ventilation and air conditioning) systems) of a healthcare facility. Infection prevention and control professionals should be involved in the design and planning of new facilities. • An Infection Control Risk assessment should be done to evaluate and mitigate potential risks for microorganism transmission by means of air, water and environmental sources. Infection Control Engineering The spatial arrangements in a well-organized operating room must meet the following requirements: 1.Clean zone 2.Hygienic zone 3.Sterile Zone Operating room 1.Clean Zone: Office environmental, common use rooms 2. Hygienic Zone The dental or surgical operating room 3.Sterile Zone The chair side surgical environmental The environmental/ clinical room The room should comply with the following: • Ceiling and walls should have intact and washable surfaces . • A suitable covering should be used i.e. tiles or washable emulsion paint. • Flooring should be intact, impervious, washable and visibly clean (no carpeted areas). • Windows should be in good condition and be visibly clean. • Cupboards and work surfaces must be structurally sound, intact, seamless and washable • The dental chair and dental surgeon’s stool material should be intact and impervious to body fluids. • There should be a designated hand wash basin with elbow-operated taps, which is not used for the decontamination of equipment. • Ideally a dirty utility area/room should be available for the decontamination of equipment and it should be within easy access of the procedure room. • In addition mechanical methods i.e. washer disinfector is recommended for the cleaning of instruments. In the absence of such facilities, there should be a designated area, with a designated sink for the pre-cleaning of contaminated equipment, within the room itself. • The work load should be managed in such a way to ensure that decontamination of equipment, including the autoclave working, does not occur whilst the patient is in the room. Surgery Design • The surgery layout should be such that there are areas for the operator and for the assistant. • The operator’s area to have access to the turbines, 3 in1 syringe, slow handpiece, bracket table, operating light and an elbow- or foot-operated hand washing sink • The nurse‘s area to contain the suction lines and perhaps the 3 in 1 syringe, curing light and the cabinetry containing the dental materials. In addition an elbow- or foot- operated sink • A designated area for clinical waste • Within these areas the design should facilitate a workflow from clean to dirty • The work surfaces should be seamless, with covered ends that prevent the accumulation of contaminated material and facilitate cleaning • The surfaces should remain clutter free Environmental Controls • Control source of infection • Dilute and remove contaminated air • Control airflow : – Keep infectious air moving outside – Keep HCWs ‘upwind’ , infectious patients ‘downwind’ Key Points • Engineering controls (EC) are the 2nd priority in control measures AFTER administrative controls, But they are complementary • Dilution ventilation is the most important EC • Negative pressure or directional airflow keeps contaminated air away from HCWs • UVGI and filtration devices are adjuncts or back-ups for highrisk areas – Require maintenance – Need to consider cost-effectiveness Natural vs Mechanical Ventilation • Good natural ventilation is better than bad mechanical ventilation. • Major limitation of natural ventilation is that it depends upon outdoor weather conditions. • Can control odour and improve comfort of occupants , but not if very cold or very hot. • Usually we do not have a choice and must work with where we are! C. Work Practice Controls Change the manner of performing tasks Examples include: • Using instruments instead of fingers to retract or palpate tissue • One-handed needle recapping YES NO YES General Cleaning Recommendations • Use barrier precautions (e.g., heavy-duty utility gloves, masks, protective eyewear) when cleaning and disinfecting environmental surfaces • Physical removal of microorganisms by cleaning is as important as the disinfection process • Follow manufacturer’s instructions for proper use of EPAregistered hospital disinfectants Surface/Environmental Barriers The benefits of surface barriers include: • less time spent performing environmental asepsis, more reliable asepsis, and visible barriers that communicate asepsis to patients. • Aseptic techniques are needed to handle and change barriers, and uncovered clinical contact surfaces must still be cleaned and disinfected between patients. Other measures that help to reduce microbial exposure 1. 2. 3. 4. Instrument sterilization Proper disinfectants Adequate air circulation Pre-treatment mouth rinse ( reduce 80% of contamination in aerosols) 5. Rubber dam 6. High-velocity air evacuation ( 80% effective in reducing aerosol) Isolate or remove the hazard Single-Use (Disposable) Devices: • Intended for use on one patient during a single procedure • Usually not heat-tolerant • Cannot be reliably cleaned • Examples: Syringe needles, prophylaxis cups, and plastic orthodontic brackets Disposal of clinical waste/Safe handling of sharps Contaminated materials must be discarded safely. • Judgment is essential in bagging medical waste so that injury or direct contact with liquids does not occur because HIV and HVB can survive beyond a few days while wet. • Separating needles and sharp into hard –walled, leak-proof, and sealable containers and out of soft trash has provided adequate safety. Appropriate handling of laundry Linen soiled with blood, body substances, secretions, and excretions must be handled, transported and processed in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of micro-organisms to healthcare workers, other patients and associated environments. Dental Unit Waterlines, Biofilm, and Water Quality • Microbial biofilms form in small bore tubing of dental units • Primary source of microorganisms is municipal water supply • Using water of uncertain quality is inconsistent with infection control principles • Untreated dental units cannot reliably produce water that meets drinking water standards Dental Handpieces and Other Devices Attached to Air and Waterlines • Clean and heat sterilize intraoral devices that can be removed from air and waterlines • Follow manufacturer’s instructions for cleaning, lubrication, and sterilization • Do not use liquid germicides or ethylene oxide Dental Radiology • The Rx equipment should not be in the operator room. • Wear gloves and other appropriate personal protective equipment as necessary • Avoid contamination of developing equipment and cover the Rx tube… Prevent cross infection Remember 1. 2. 3. 4. 5. Hand washing (hand hygiene); Use of personal protective equipment Environmental cleaning Appropriate handling of waste and Taking care of yourself (e.g. immunization) Thank you